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

Quality of life among people living with mental illness and predictors in Africa: a systematic review and meta-analysis

INTRODUCTION

Quality of life (QoL) of patients with mental illness has been examined internationally but to a lesser extent in developing countries, including countries in Africa. Improving QoL is vital to reducing disability among people with mental illness. Therefore, this systematic review and meta-analysis aimed to assess the prevalence of QoL and associated factors among people living with mental illness in Africa.

METHODS

Using the PICOT approach, Scopus, MEDLINE, PsycINFO, CINAHL, Embase, the Web of Science, and Google Scholar were searched. A structured search was undertaken, comprising terms associated with mental health, mental illness, QoL, and a list of all African countries. The Joanna Briggs Institute Quality Appraisal Checklist is used to evaluate research quality. Subgroup analysis with Country, domains of QoL, and diagnosis was tested using a random-effect model, and bias was assessed using a funnel plot and an inspection of Egger's regression test. A p value, OR, and 95% CI were used to demonstrate an association.

RESULTS

The pooled prevalence of poor QoL was 45.93% (36.04%, 55.83%), I2 = 98.6%, p < 0.001). Subgroup analysis showed that Ethiopia (48.09%; 95% CI = 33.73, 62.44), Egypt (43.51%; 95% CI = 21.84, 65.18), and Nigeria (43.49%; 95% CI = 12.25, 74.74) had the highest mean poor QoL prevalence of the countries. The pooled prevalence of poor QoL by diagnosis was as follows: bipolar disorder (69.63%; 95% CI = 47.48, 91.77), Schizophrenia (48.53%; 95% CI = 29.97, 67.11), group of mental illnesses (40.32%; 95% CI = 23.98, 56.66), and depressive disorders (38.90%; 95% CI = 22.98, 54.81). Being illiterate (3.63; 95% CI = 2.35, 4.91), having a comorbid medical illness (4.7; 95% CI = 2.75, 6.66), having a low monthly income (3.62; 95% CI = 1.96, 5.27), having positive symptoms (0.32; 95% CI = 0.19, 0.55), and having negative symptoms (0.26; 95% CI = 0.16, 0.43) were predictors of QoL. Thus, some factors are significantly associated with pooled effect estimates of QoL.

CONCLUSIONS

The current systematic review and meta-analysis showed that almost half of patients with mental illness had poor QoL. Being illiterate, having a comorbid medical condition, having a low monthly income, having positive symptoms, and having negative symptoms of mental illness were independent predictors of poor QoL. This systematic review and meta-analysis emphasize that poor QoL of people with mental illness in Africa needs attention to reduce its negative consequences.

"What makes you well?" Supports of well-being in bipolar disorder. A qualitative study

OBJECTIVE

Subjective experience of people living with bipolar disorder is gaining attention in the field of research. Improving well-being could be as important as symptom remission, but this constitutes a vague concept. This study aimed at exploring the boundaries and the determinants of the well-being of people living with bipolar disorder in a French context.

METHODS

Individual semi-structured interviews were conducted with 16 patients by three professionals. Interviews were transcribed and analysed using the thematic analysis method.

RESULTS

Various dimensions emerged as contributing to well-being: daily routines, connectedness, regaining a positive identity, and self-awareness for self-management.

CONCLUSIONS

In addition to those common to the general population, this study highlighted specific determinants of well-being: the construction of a positive identity through acceptance of the diagnosis, the importance of self-awareness and self-management. They are highly intertwined with those of personal recovery and could help caregivers design interventions that directly target these goals. This study aimed to identify specific components of well-being for people living with bipolar disorder. Understanding the determinants of well-being enable caregivers to design tailored interventions that directly target quality of life and help improve bipolar disorder outcomes.

Quality of life, social support, and pathways of care among persons with psychiatric disorders-A cross-sectional study

Background

Patients with psychiatric disorders have varied psychosocial realities embedded in the community context. Help-seeking behavior is extremely crucial in determining the prognosis and outcome of interventions.

Objectives

(1) To assess the levels of quality of life, perceived social support, and decision to first seek help. (2) To assess the association of socio-demographic variables with these domains.

Materials and Methods

A cross-sectional descriptive survey with 100 psychiatric patients in a tertiary care setting employed three scales, namely WHOQOL-BREF, PSSS, and WHO Pathways Encounter form.

Results

Patients had higher levels of quality of life and perceived social support. The majority of patients chose health professionals over faith healers at the onset of symptoms, had higher reliance on family members, and continued with hospital visits till the third follow-up. Sex, occupation, and marital status were associated with perceived social support, and duration of illness was associated with help-seeking behavior.

Conclusions

Community-based interventions must include holistic services and reduce the gap between onset and first contact, leading to higher quality of life and perceived social support.

Posting patterns in peer online support forums and their associations with emotions and mood in bipolar disorder: Exploratory analysis

BACKGROUND

Mental health (MH) peer online forums offer robust support where internet access is common, but healthcare is not, e.g., in countries with under-resourced MH support, rural areas, and during pandemics. Despite their widespread use, little is known about who posts in such forums, and in what mood states. The discussion platform Reddit is ideally suited to study this as it hosts forums (subreddits) for MH and non-MH topics. In bipolar disorder (BD), where extreme mood states are core defining features, mood influences are particularly relevant.

OBJECTIVES

This exploratory study investigated posting patterns of Reddit users with a self-reported BD diagnosis and the associations between posting and emotions, specifically: 1) What proportion of the identified users posts in MH versus non-MH subreddits? 2) What differences exist in the emotions that they express in MH or non-MH subreddit posts? 3) How does mood differ between those users who post in MH subreddits compared to those who only post in non-MH subreddits?

METHODS

Reddit users were automatically identified via self-reported BD diagnosis statements and all their 2005-2019 posts were downloaded. First, the percentages of users who posted only in MH (non-MH) subreddits were calculated. Second, affective vocabulary use was compared in MH versus non-MH subreddits by measuring the frequency of words associated with positive emotions, anxiety, sadness, anger, and first-person singular pronouns via the LIWC text analysis tool. Third, a logistic regression distinguished users who did versus did not post in MH subreddits, using the same LIWC variables (measured from users' non-MH subreddit posts) as predictors, controlling for age, gender, active days, and mean posts/day.

RESULTS

1) Two thirds of the identified 19,685 users with a self-reported BD diagnosis posted in both MH and non-MH subreddits. 2) Users who posted in both MH and non-MH subreddits exhibited less positive emotion but more anxiety and sadness and used more first-person singular pronouns in their MH subreddit posts. 3) Feminine gender, higher positive emotion, anxiety, and sadness were significantly associated with posting in MH subreddits.

CONCLUSIONS

Many Reddit users who disclose a BD diagnosis use a single account to discuss MH and other concerns. Future work should determine whether users exhibit more anxiety and sadness in their MH subreddit posts because they more readily post in MH subreddits when experiencing lower mood or because they feel more able to express negative emotions in these spaces. MH forums may reflect the views of people who experience more extreme mood (outside of MH subreddits) compared to people who do not post in MH subreddits. These findings can be useful for MH professionals to discuss online forums with their clients. For example, they may caution them that forums may underrepresent people living well with BD.

Why patients diagnosed with bipolar disorder start, continue or discontinue health-related apps supporting their self-management

WHAT IS KNOWN ABOUT THE SUBJECT?: Self-management is essential in the treatment of those who have bipolar disorder. There are many apps to support self-management, but we know that these apps only sometimes cover the users' needs. WHAT IS ADDED TO EXISTING KNOWLEDGE?: In our research, we made an inventory of apps that people with bipolar disorder use to cover their needs in self-management. We also have searched for the reasons to start, continue, switch or quit the use of those apps. We found that 44% (n = 18) of our respondents use health-related apps for self-management purposes. Apps for physical activity, planning and structure and apps for relaxation were most used. In the use of apps, the "freedom of choice" and user-friendliness are the most important in continuing the use of apps, while malfunctioning and "not fitting in individual needs" the main reasons were for quitting the use of apps.

IMPLICATIONS FOR PRACTICE

Various apps can be used for self-management purposes as long as these apps meet the individual user's requirements. Clinicians and patients should have a broad view when looking for suitable apps and not limit the search to just professional apps. In developing new apps, patients, clinicians and developers should collaborate in the development process, requirements and design.

ABSTRACT

INTRODUCTION: Self-management is one of the cornerstones in the treatment of bipolar disorder (BD). Complementing interventions by apps are seen as a good opportunity to support self-management. However, there is insufficient knowledge about understanding the use of health-related applications by consumers with BD for self-management purposes.

AIM

The study aims to gain insight from patients diagnosed with BD about reasons to use, continue or discontinue health-related apps.

METHOD

This study employed a mixed-method design in which 41 participants diagnosed with BD participated in a quantitative survey, and 11 participants also participated in an in-depth interview.

RESULTS

The survey showed that 44% (n = 18) of the participants use health-related apps, and 26.8% (n = 11) use those apps consistently. Interviews revealed that adjustability, usability, trustworthiness and the guarantee of privacy were the main reasons determining whether participants used or terminated the use of a health-related app.

IMPLICATIONS FOR PRACTICE

Although we found that a substantial number of patients diagnosed with BD use one or more apps to support self-management, their use is often discontinued due to content that needs more robust to address their needs. Besides appropriate content, tailoring and persuasive technologies will likely promote the continued use of an app for self-management purposes. Cooperation between those diagnosed with bipolar disorder and health professionals (like mental health nurses) in developing and designing applications that are aimed to support self-management in BD is necessary for successful implementation and adaptation.

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.

Personal recovery in bipolar disorder: Systematic review and "best fit" framework synthesis of qualitative evidence - a POETIC adaptation of CHIME

BACKGROUND

Personal recovery, living a satisfying, hopeful life alongside symptoms, has become an increasingly valued aim across mental health care agendas internationally. However, there is little understanding of how people experience personal recovery alongside the mood challenges characteristic of a bipolar disorder diagnosis. Personal recovery frameworks have been developed for populations with mixed psychiatric diagnoses, predominantly psychotic disorders.

METHODS

This systematic review of qualitative data used the widely adopted personal recovery processes Connectedness, Hope and optimism, Identity, Meaning and purpose, Empowerment (CHIME) in a "best fit" framework synthesis to understand personal recovery experiences in bipolar disorder. Included studies were coded with deductive framework analysis based on the CHIME processes and inductive thematic analysis for aspects beyond the a priori framework.

RESULTS

A comprehensive search of six literature databases led to inclusion of twelve articles published 2010-2020. Deductive coding supported the fit with the CHIME framework but revealed difficulties, losses, and tensions within and across recovery processes. The proposed framework for personal recovery in bipolar disorder, Purpose and meaning, Optimism and hope, Empowerment, Tensions, Identity, Connectedness (POETIC), organises all CHIME processes around these tensions.

LIMITATIONS

Diversity among study participants was limited with majority middle-aged, female, Western participants.

CONCLUSIONS

The compact POETIC personal recovery framework tailored for bipolar disorder is directly applicable to clinical practice with personal recovery objectives. It highlights the need for professionals to introduce personal recovery in a realistic and balanced way to address recent criticism by service user organisations of personal recovery as overly optimistic.

Quality of life and subjective sleep-related measures in bipolar disorder and major depressive disorder

Purpose

Diminished quality of life (QoL) has been reported in patients with mood disorders. QoL has also been shown to be decreased by sleep disturbances. Since sleep disorders are common in mood disorders, the aim of this study was to determine whether sleep characteristics are associated to QoL among patients with Bipolar Disorder (BD) and unipolar Major Depressive Disorders (MDD).

Methods

QoL was assessed in 170 patients with mood disorders (61 BD and 109 MDD), who also completed questionnaires measuring the severity of insomnia, sleepiness, chronotype preference and obstructive sleep apnea (OSA) probability index.

Results

Analyses showed that BD and MDD groups had similar QoL and sleep measures but the MDD group had higher OSA scores. In BD, correlations indicated a relationship between QoL and insomnia complaints and sleepiness, whereas in MDD, correlations indicated an association between QoL and insomnia complaints and OSA score. In both groups, QoL was related to depressive symptomatology. Linear regressions showed that, in BD, QoL was related to insomnia complaints and sleepiness even in the euthymic state, whereas in MDD, QoL was related to insomnia complaints but not in euthymic patients.

Conclusion

QoL is related to sleep differently in BD and MDD. The results suggest that insomnia and sleepiness are particularly high in BD even when patients are euthymic. These findings suggest that focusing on insomnia and sleepiness during different mood states of BD could increase QoL.

Predictors of Quality of Life Improvement with Escitalopram and Adjunctive Aripiprazole in Patients with Major Depressive Disorder: A CAN-BIND Study Report

BACKGROUND

Non-response to first-line treatment for major depressive disorder (MDD) is common; for such individuals, quality of life (QoL) impairments can be severe. Identifying predictors of QoL changes may support the management of cases with persistent depressive symptoms despite adequate initial pharmacological/psychological treatment.

OBJECTIVE

The present study aimed to explore predictors of domain-specific QoL improvement following adjunctive aripiprazole treatment for inadequate response to initial antidepressant therapy.

METHODS

We evaluated secondary QoL outcomes from a CAN-BIND (Canadian Biomarker Integration Network in Depression) study in patients with MDD who did not respond to an initial 8 weeks of escitalopram and received a further 8 weeks of adjunctive aripiprazole (n = 96). Physical, psychological, social, and environmental QoL domains were assessed using the World Health Organization QoL Scale Brief Version (WHOQOL-BREF). Clinician-rated depressive symptoms were assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS). Functioning was measured with the Sheehan Disability Scale (SDS). Satisfaction with medication was assessed with a single item from the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). Exploratory t-tests were used to describe domain score changes. A hierarchical linear regression was used to explore demographic, clinical, and treatment-related predictors of improvement.

RESULTS

Across domains, QoL improved with adjunctive aripiprazole treatment. Satisfaction with medication and MADRS and SDS scores similarly improved. Symptom reduction was a predictor for positive change to physical and psychological QoL; functioning improvements were predictive of increases to all QoL domains. Satisfaction with medication predicted improvements to physical and psychological domains, whereas number of medication trials was a predictor of worsening QoL in the physical domain.

CONCLUSION

The final model explained the most variance in psychological (68%) and physical (67%) QoL. Less variance was explained for environmental (43%) and social QoL (33%), highlighting a need for further exploration of predictors in these domains. Strategies such as functional remediation may have potential to support QoL for individuals with persistent depressive symptoms.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov identifier: NCT016557.

The Quality of Life in Bipolar Disorder (QoL.BD) Scale: Validation of a French Cross-Cultural Adaptation

OBJECTIVE

The goal of this study was to validate the French version of the Quality of Life in Bipolar Disorder (QoL.BD) scale, a condition-specific measure for bipolar disorder (BD).

METHOD

The QoL.BD scale was translated into French in accordance with the recommendations for transcultural adaptation. It was administered to 125 participants with BD living in Quebec, Canada. Construct validity was evaluated through correlations with other measures of self-reported quality of life (QoL), functioning, and symptoms. Factorial structure was examined through an exploratory factor analysis.

RESULTS

Internal reliability and test-retest reliability standards were met. Correlations in expected directions with other QoL, functioning, and depressive symptom scales supported convergent validity. The item loadings structure of the French QoL.BD largely replicated the original English version, with some modifications.

CONCLUSION

The French version of the QoL.BD (full and brief) is comparable in its psychometric properties to the English version. It is a valid and sound measure for the evaluation of the QoL of French-speaking patients with BD.

Have I argued with my family this week?": What questions do those with lived experience choose to monitor their bipolar disorder?

BACKGROUND

Electronic self-report mood monitoring tools for individuals with bipolar disorder (BD) are rapidly emerging and predominately employ predefined symptom-based questions. Allowing individuals to additionally choose what they monitor in relation to their BD offers the unique opportunity to capture and gain a deeper insight into patient priorities in this context.

METHODS

In addition to monitoring mood symptoms with two standardised self-rated questionnaires, 308 individuals with BD participating in the Bipolar Disorder Research Network True Colours electronic mood-monitoring tool for research chose to create and complete additional personalised questions. A content analysis approach was used to analyse the content of these questions.

RESULTS

35 categories were created based on the personalised questions with the most common being physical activity and exercise, anxiety and panic, sleep and coping/stress levels. The categories were grouped into six overarching themes 1) mental health; 2) behaviour and level of functioning; 3) physical wellbeing; 4) health behaviours; 5) active self-management; and, 6) interpersonal.

LIMITATIONS

The average age of the sample was around 50 years meaning our findings may not be generalisable to younger individuals with BD.

CONCLUSIONS

Aspects of BD important to patients in relation to longitudinal monitoring extend well beyond mood symptoms, highlighting the limitations of solely relying on standardised questions/mood rating scales based on symptoms primarily used for diagnosis. Additional symptoms and aspects of life not necessarily useful diagnostically for BD may be more important for individuals themselves to monitor and have more meaning in capturing their own experience of changes in BD severity.

The Quality of Life in Bipolar Disorder (QoL.BD) questionnaire a decade on - A systematic review of the measurement of condition-specific aspects of quality of life in bipolar-disorder

BACKGROUND

Condition-specific quality of life (QoL) instruments are more representative of the priorities of people with lived experience. As such, the development of the first and only bipolar disorder (BD) specific measurement instrument, the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire, marked an important step forward for the literature. The present systematic review aims to characterise applications of the QoL.BD in the BD literature and review empirical findings obtained from studies using this measure.

METHODS

A systematic search identified 37 peer-reviewed publications which reported original empirical data using the QoL.BD in a BD population. No restrictions were placed on language/study type.

RESULTS

Adaptations to the QoL.BD displayed appropriate psychometric properties. Although clinical trials were typically underpowered, promising effect sizes for a number of treatment modalities were reported. QoL.BD scores were moderately correlated with depressive symptoms; a number of candidate predictors were identified.

LIMITATIONS

Due to resource limitations, the present review used one database (Google Scholar), and a single author reviewed articles for eligibility. On balance the risks of missing relevant studies were deemed minimal.

CONCLUSION

A sizeable, international body of evidence now exists regarding the measurement, presentation, and treatment of condition-specific aspects of QoL in BD. Key avenues for future research include large scale, randomized control clinical trials using the QoL.BD as a primary outcome, and granular exploration of potential correlates of QoL.BD domain scores. Finally, longer follow-up periods are required to inform understanding of the dynamic relationship between clinical variables and condition-specific aspects of QoL in BD.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Improving quality of life assessments for high-need adult Medicaid service users with mental health conditions

PURPOSE

There is a lack of consensus on how to evaluate health and social service programs for people with mental health (MH) conditions. Having service users be the primary decision makers in selecting outcome measures can inform a meaningful evaluation strategy. We sought to identify the quality of life (QoL) survey preferences of high-need adult service users with MH conditions.

METHODS

A systematic review identified generic, self-reported QoL surveys with evidence of validity in MH populations of interest. An advisory panel selected the most promising surveys to assess the success of programs like Medicaid for MH service users. Three groups of high-need, adult service users with MH conditions and one group of direct care staff ranked the surveys from the advisory panel, and generated and ranked characteristics that were desirable or undesirable in a QoL survey.

RESULTS

Twenty-two surveys met the inclusion criteria. Of the six surveys selected by the advisory panel, groups of service users and direct care staff most preferred the Warwick-Edinburg Mental Well-being Scale (WEMWBS). The WEMWBS best embodied the features prioritized by the groups: to have a user-friendly format and positive focus, to be clearly worded and brief, and to avoid presumptive or unrealistic items. Service user groups appreciated survey topics most amenable to self-report, such as satisfaction with relationships.

CONCLUSION

Using QoL surveys that service users prefer can reduce the chance that deteriorating QoL is going unchecked, and increase the chance that decisions based on survey findings are meaningful to service users.

Cognitive remediation for the treatment of neuropsychological disturbances in subjects with euthymic bipolar disorder: findings from a controlled study

INTRODUCTION

Individuals with euthymic Bipolar Disorder (BD) can experience deteriorated cognitive functioning, with such deterioration being associated with functional impairment. Cognitive remediation (CR) is considered an effective add-on intervention for neuropsychological impairments, but relatively few CR controlled studies have been performed on BD. In the present study the efficacy of a CR intervention designed for the improvement of cognition and functioning in patients with euthymic BD was tested.

METHODS

Patients (n = 54) with euthymic BD were assigned to receive active (n = 27) or control (n = 27) intervention. The active intervention (i.e. the Cognitive Remediation in Integrated Treatment - CRIIT - protocol) was made of 20 individual sessions focused on the treatment of attention, memory and executive functioning through the COGPACK software; each session was integrated with psychoeducation and rehabilitation interventions implemented through a metacognitive approach aimed at ameliorating personal agency.

RESULTS

A significant (p ≤ 0.015) time x group interaction at repeated measures MANOVA was observed on Rey Auditory Verbal Learning Test, Rey Complex Figure Test, Wisconsin Card Sorting Test, Trail Making Test, Visual Search, Life Skills Profile, and Barratt Impulsiveness Scale.

LIMITATIONS

A single-blind approach was used.

DISCUSSION

The results showed that patients undergoing active intervention improved in domains related to executive functions, attention, memory, functioning and impulsivity more significantly than patients undergoing control interventions. This study adds to the evidence that CR improves neurocognition in BD, and suggests that CRIIT protocol represents an add-on intervention of potential relevance to increase cognition and functioning in BD euthymic patients.

Quality of life in patients with severe mental illness: a cross-sectional survey in an integrated outpatient health care model

PURPOSE

This study (a) assessed quality of life (QoL) in a patient sample with severe mental illness in an integrated psychiatric care (IC) programme in selected regions in Germany, (b) compared QoL among diagnostic groups and (c) identified socio-demographic, psychiatric anamnestic and clinical characteristics associated with QoL.

METHODS

This cross-sectional study included severely mentally ill outpatients with substantial impairments in social functioning. Separate dimensions of QoL were assessed with the World Health Organisation's generic 26-item quality of life (WHOQOL-BREF) instrument. Descriptive analyses and analyses of variance (ANOVAs) were conducted for the overall sample as well as for diagnostic group.

RESULTS

A total of 953 patients fully completed the WHOQOL-BREF questionnaire. QoL in this sample was lower than in the general population (mean 34.1; 95% confidence interval (CI) 32.8 to 35.5), with the lowest QoL in unipolar depression patients (mean 30.5; 95% CI 28.9 to 32.2) and the highest in dementia patients (mean 53.0; 95% CI 47.5 to 58.5). Main psychiatric diagnosis, living situation (alone, partner/relatives, assisted), number of disease episodes, source of income, age and clinical global impression (CGI) scores were identified as potential predictors of QoL, but explained only a small part of the variation.

CONCLUSION

Aspects of health care that increase QoL despite the presence of a mental disorder are essential for severely mentally ill patients, as complete freedom from the disorder cannot be expected. QoL as a patient-centred outcome should be used as only one component among the recovery measures evaluating treatment outcomes in mental health care.

A Web-Based Adaptation of the Quality of Life in Bipolar Disorder Questionnaire: Psychometric Evaluation Study

BACKGROUND

Quality of life (QoL) is considered a key treatment outcome in bipolar disorder (BD) across research, clinical, and self-management contexts. Web-based assessment of patient-reported outcomes offer numerous pragmatic benefits but require validation to ensure measurement equivalency. A web-based version of the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire was developed (QoL Tool).

OBJECTIVE

This study aimed to evaluate the psychometric properties of a web-based QoL self-report questionnaire for BD (QoL Tool). Key aims were to (1) characterize the QoL of the sample using the QoL Tool, (2) evaluate the internal consistency of the web-based measure, and (3) determine whether the factor structure of the original version of the QoL.BD instrument was replicated in the web-based instrument.

METHODS

Community-based participatory research methods were used to inform the development of a web-based adaptation of the QoL.BD instrument. Individuals with BD who registered for an account with the QoL Tool were able to opt in to sharing their data for research purposes. The distribution of scores and internal consistency estimates, as indicated by Cronbach alpha, were inspected. An exploratory factor analysis using maximum likelihood and oblique rotation was conducted. Inspection of the scree plot, eigenvalues, and minimum average partial correlation were used to determine the optimal factor structure to extract.

RESULTS

A total of 498 people with BD (349/498, 70.1% female; mean age 39.64, SD 12.54 years; 181/498, 36.3% BD type I; 195/498, 39.2% BD type II) consented to sharing their QoL Tool data for the present study. Mean scores across the 14 QoL Tool domains were, in general, significantly lower than that of the original QoL.BD validation sample. Reliability estimates for QoL Tool domains were comparable with that observed for the QoL.BD instrument (Cronbach alpha=.70-.93). Exploratory factor analysis supported the extraction of an 11-factor model, with item loadings consistent with the factor structure suggested by the original study. Findings for the sleep and physical domains differed from the original study, with this analysis suggesting one shared latent construct.

CONCLUSIONS

The psychometric properties of the web-based QoL Tool are largely concordant with the original pen-and-paper QoL.BD, although some minor differences in the structure of the sleep and physical domains were observed. Despite this small variation from the factor structure identified in the QoL.BD instrument, the latent factor structure of the QoL Tool largely reproduced the original findings and theoretical structure of QoL areas relevant to people with BD. These findings underscore the research and clinical utility of this instrument, but further comparison of the psychometric properties of the QoL Tool relative to the QoL.BD instrument is warranted. Future adaptations of the QoL Tool, including the production of an app-based version of the QoL Tool, are also discussed.

The Impact of Subsyndromal Bipolar Symptoms on Patient's Functionality and Quality of Life

Subsyndromal symptoms have rarely been in the focus of bipolar research. This may be, in part, due to the fact that there is neither a uniform definition nor do they constitute an indication of regulatory and commercial interest. Nevertheless, they do have a decisive impact on the long-term course of bipolar disorder (BD), and the degree of functionality and quality of life (QoL) is more likely determined by their presence or absence than by acute episodes. Summarizing the literature an estimated 20-50% of patients suffer inter-episodically or chronically from subsyndromal BD. The most prominent symptoms that interfere with functionality are subsyndromal depression, disturbances of sleep, and perceived cognitive impairment, whereas anxiety negatively impacts on QoL. In the absence of evidence-based pharmacological treatments for subsyndromal BD, clinical practice adopts guidelines designed for treatment-resistant full-blown episodes of BD, supplemented by cognitive-behavioral, family focused or social-rhythm-based psychotherapies.

Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration

BACKGROUND

Self-monitoring of symptoms is a cornerstone of psychological interventions in bipolar disorder (BD), but individuals with lived experience also value tracking holistic outcomes, such as quality of life (QoL). Importantly, self-monitoring is not always experienced positively by people with BD and may have lower than expected rates of engagement. Therefore, before progressing into QoL tracking tools, it is important to explore user perspectives to identify possible risks and benefits, optimal methods to support engagement, and possible avenues to integrate QoL self-monitoring practices into clinical work.

OBJECTIVE

This study aimed to conduct a qualitative exploration of how individuals with BD engaged with a Web-based version of a BD-specific QoL self-monitoring instrument, the QoL tool.

METHODS

A total of 43 individuals with BD engaged with a self-management intervention with an optional Web-based QoL self-assessment tool as part of an overarching mixed method study. Individuals were later interviewed about personal experiences of engagement with the intervention, including experiences of gauging their own QoL. A thematic analysis was used to identify salient aspects of the experience of QoL self-monitoring in BD.

RESULTS

In total, 4 categories describing people's experiences of QoL self-monitoring were identified: (1) breadth of QoL monitoring, (2) highlighting the positive, (3) connecting self-monitoring to action, and (4) self-directed patterns of use.

CONCLUSIONS

The findings of this research generate novel insights into ways in which individuals with BD experience the Web-based QoL self-assessment tool. The value of tracking the breadth of domains was an overarching aspect, facilitating the identification of both areas of strength and life domains in need of intervention. Importantly, monitoring QoL appeared to have an inherently therapeutic quality, through validating flourishing areas and reinforcing self-management efforts. This contrasts the evidence suggesting that symptom tracking may be distressing because of its focus on negative experiences and positions QoL as a valuable adjunctive target of observation in BD. Flexibility and personalization of use of the QoL tool were key to engagement, informing considerations for health care providers wishing to support self-monitoring and future research into Web- or mobile phone-based apps.

Improving Functioning, Quality of Life, and Well-being in Patients With Bipolar Disorder

People with bipolar disorder frequently experience persistent residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life. In the last decade, the treatment target in clinical and research settings has focused not only on clinical remission, but also on functional recovery and, more lately, in personal recovery, taking into account patients' well-being and quality of life. Hence, the trend in psychiatry and psychology is to treat bipolar disorder in an integrative and holistic manner. This literature review offers an overview regarding psychosocial functioning in bipolar disorder. First, a brief summary is provided regarding the definition of psychosocial functioning and the tools to measure it. Then, the most reported variables influencing the functional outcome in patients with bipolar disorder are listed. Thereafter, we include a section discussing therapies with proven efficacy at enhancing functional outcomes. Other possible therapies that could be useful to prevent functional decline and improve functioning are presented in another section. Finally, in the last part of this review, different interventions directed to improve patients' well-being, quality of life, and personal recovery are briefly described.

Subjective neurocognition and quality of life in patients with bipolar disorder and siblings

BACKGROUND

Bipolar disorder (BD) is associated with significant neurocognitive and functional impairment, which may progress across stages. However, the potential progression of subjective cognitive complaints and quality of life (QoL) has not been addressed. Our main objective was to assess subjective cognitive complaints and QoL on euthymic patients with BD and their healthy siblings.

METHODS

Four groups were compared: euthymic patients with type I BD in the early (n = 25) and late (n = 23) stages, their healthy siblings (latent stage; n = 23) and healthy controls (n = 21). Cognitive complaints and QoL were assessed using the COBRA and WHO-QoLBREF questionnaires, respectively.

RESULTS

Late-stage patients had greater number of subjective cognitive complaints and reported a worse QoL compared to the other groups. Early-stage patients also had more cognitive complaints than controls and siblings, although differences were not significant. Siblings and controls reported similar QoL.

LIMITATIONS

the most important limitation of this study is the criterion used to define the early and late stages of BD, as currently there is no consensus and previous studies have used different criteria.

CONCLUSIONS

This is the first study to examine subjective cognition and QoL in patients with BD and siblings. Our results raise the possibility that burden of cognitive complaints increase with disorder progression, in tandem with deterioration in subjective QoL. That would support a clinical staging model of BD. This hypothesis remains to be confirmed by a longitudinal analysis.

Clinical significance of neutrophil-lymphocyte and platelet-lymphocyte ratios in bipolar patients: An 18-month prospective study

Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) have recently been investigated as inexpensive and reproducible markers of systemic inflammation in many diseases. However, few studies evaluate clinical and prognostic value of NLR and PLR in psychiatric patients. The objective of this study is to investigate the clinical repercussions of NLR and PLR in patients with bipolar disorder (BD). An 18-month prospective study followed up eighty euthymic BD outpatients. Baseline data included an interviewer-administered questionnaire, behavioral scales and a blood count to calculate NLR and PLR. The occurrence of mood episodes and hospitalizations was assessed monthly for 18 months. Higher NLR and PRL were associated with more anxious symptoms and poorer functioning. BD patients with Night Eating Syndrome (NES) had higher PLR and tended to higher NLR. No association with other sleep parameters was evidenced. Higher NLR and PRL were also associated with more episodes and hospitalizations after 18 months. However, only higher baseline NLR was related to more (hypo)mania episodes. NLR and PLR are important prognostic factor for BD. This study suggested the importance of a simple blood count, an inexpensive and reproducible exam, in evaluating the course of the BD. Further studies must be performed to confirm these results.

Quality of life in euthymic patients with unipolar major depressive disorder and bipolar disorder

Objective: This study aimed to compare quality of life (QOL) between patients with major depressive disorder (MDD) in remission and patients with bipolar disorder (BD) in remission, and to explore the relationship between QOL and demographic, clinical, and cognitive variables. Methods: This study included 49 euthymic patients with MDD, 59 euthymic patients with BD, and 52 healthy controls (HC). The 17-item Hamilton Depression Rating Scale (HAMD-17), Hamilton Anxiety Rating Scale (HAMA), and Young Mania Rating Scale (YMRS) were used to assess symptoms of depression, anxiety, and mania respectively. QOL was assessed with the Chinese version of the World Health Organization Quality of Life Scale Brief (WHOQOL-BREF). Cognitive function was assessed with the repeated neuropsychological assessment scale (RBANS). Results: Compared with HC, patients with MDD had lower overall and subdomain scores (except ENVIR) on the WHOQOL-BREF (p<0.05). The BD group had decreased overall WHOQOL-BREF scores and decreased PHYS and SOCIL subdomain scores (p<0.05). PSYCH scores were lower in patients with MDD, compared with patients with BD (p<0.05). Among patients with MDD, HAMD score was negatively correlated with all domains on the WHOQOL-BREF. Marital status was associated with an increase in subdomain scores on the PSYCH and ENVIR subdomains. In the BD group, attention on the RBANS correlated negatively with PSYCH score; age correlated negatively with SOCIL. Conclusions: QOL of patients with MDD and BD in remission is inferior to that of the normal population. QOL among MDD is inferior to that among BD. Marital status was associated with increased QOL among MDD, but not among BD. Residual symptoms related to depression or anxiety decreased QOL in both MDD and BD. More attention should be paid to the QOL of patients with mood disorders, especially MDD, even during euthymic periods.

What Would Digital Early Intervention for Bipolar Disorder Look Like? Theoretical and Translational Considerations for Future Therapies

There are growing calls for the development of early intervention/preventive interventions for young people identified to be at risk of bipolar disorder (BD), and digital delivery appears to be a strong candidate delivery method. To date, no such interventions exist, and the aim of this perspective paper is to advance the literature by reviewing theoretical issues related to early intervention in BD and introducing a framework for design of feasible, acceptable, and effective online psychosocial interventions for this population. It is concluded that, by adopting an appropriate transdiagnostic and humanistic framework, and recognizing emerging tenets of digital psychotherapy development, testable online interventions for young people at risk of BD are within reach.

[Influence of a therapeutic patient education (TPE) program on quality of life in bipolar disorder: Preliminary results]

INTRODUCTION

Bipolar disorder is a mental illness that is associated with a long-term impairment in psychosocial functioning and quality of life. The objective of this study was to evaluate the influence of a therapeutic education program on the quality of life of patients with bipolar disorder (type 1 or 2).

METHOD

This study included 18 patients with bipolar disorder (type 1 or 2) following the therapeutic education program on bipolar disorder which includes 8 sessions of 2hours each. The assessment of quality of life and mood, self-esteem, insight and global functioning was performed before and after the program using the following tools: World Health Organization Quality Of Life questionnaire in short version (WHOQOL-Bref), Hamilton Depression Rating Scale, Young Mania Rating Scale, Rosenberg Self-Esteem Scale, Birchwood Insight Scale and Global Assessment of Functioning Scale. The total score of WHOQOL-Bref constitutes the primary study outcome. The under-scores of WHOQOL-Bref as insight, self-esteem, functioning, depression and mania scores constitute secondary outcomes.

RESULTS

Our results show an improvement in quality of life, regarding global and main dimension scores of WHOQOL-Bref. The mean total scores for quality of life at the beginning and the end of the program were respectively 55.47/100 (standard deviation=14.11) and 60.03/100 (standard deviation=12.62). However, the difference was still not significant even after statistical adjustment with depression, mania and functioning scores. Self-esteem was significantly improved (P=0.0469). Quality of life and self-esteem evolutions were strongly related (correlation coefficient=0.80, P=0.0006). At the end of the program, the less depressed the patients were, the better their quality of life was (correlation coefficient=0.67, P=0.0090). We did not find any correlation between quality of life and mania intensity or global functioning level at the end of the program.

CONCLUSION

This study suggests a need to focus on self-esteem perception in order to understand and ameliorate the quality of life of patients with bipolar disorders. Going further, the use of bipolar disorder specific scales to assess quality of life would be more relevant.

Quality of life in bipolar disorder: towards a dynamic understanding

BACKGROUND

Although quality of life (QoL) is receiving increasing attention in bipolar disorder (BD) research and practice, little is known about its naturalistic trajectory. The dual aims of this study were to prospectively investigate: (a) the trajectory of QoL under guideline-driven treatment and (b) the dynamic relationship between mood symptoms and QoL.

METHODS

In total, 362 patients with BD receiving guideline-driven treatment were prospectively followed at 3-month intervals for up to 5 years. Mental (Mental Component Score - MCS) and physical (Physical Component Score - PCS) QoL were measured using the self-report SF-36. Clinician-rated symptom data were recorded for mania and depression. Multilevel modelling was used to analyse MCS and PCS over time, QoL trajectories predicted by time-lagged symptoms, and symptom trajectories predicted by time-lagged QoL.

RESULTS

MCS exhibited a positive trajectory, while PCS worsened over time. Investigation of temporal relationships between QoL and symptoms suggested bidirectional effects: earlier depressive symptoms were negatively associated with mental QoL, and earlier manic symptoms were negatively associated with physical QoL. Importantly, earlier MCS and PCS were both negatively associated with downstream symptoms of mania and depression.

CONCLUSIONS

The present investigation illustrates real-world outcomes for QoL under guideline-driven BD treatment: improvements in mental QoL and decrements in physical QoL were observed. The data permitted investigation of dynamic interactions between QoL and symptoms, generating novel evidence for bidirectional effects and encouraging further research into this important interplay. Investigation of relevant time-varying covariates (e.g. medications) was beyond scope. Future research should investigate possible determinants of QoL and the interplay between symptoms and wellbeing/satisfaction-centric measures of QoL.

Psychometric properties of the well-being index (WHO-5) spanish version in a sample of euthymic patients with bipolar disorder

BACKGROUND

The concept of well-being which focuses on positive emotions has received increased research attention. However, a consensus definition of this term is lacking. The Well-Being Index scale (WHO-5) is a generic, self-report scale that contains five Likert-type items to evaluate psychological well-being. This construct may provide a relevant outcome in bipolar disorder (BD) research and care beyond the rating of mood symptoms. Thus, in the current study, the psychometric properties of the WHO-5 Spanish version were assessed in a sample of euthymic patients with BD.

METHODS

Patients with BD- I and BD-II and healthy controls completed the Well-Being Index (WHO-5) together with an assessment of depressive (Hamilton Depression Rating Scale-17; HAM-D) and manic symptoms (Young Mania Rating Scale; YMRS); and a measure of psychosocial functioning (Functioning Assessment Short Test; FAST). Internal consistency reliability was measured through Cronbach's alpha. Test-retest reliability was calculated comparing the WHO-5 total score at baseline and after 10 days of the first administration. To assess the structure of the scale, a principal component analysis (PCA) was carried out. Correlations between the WHO-5, HAM-D, YMRS and FAST were calculated. Finally, a t-test for independent samples was applied to compare the WHO-5 total score in the patient and control groups.

RESULTS

A total of 104 patients with BD and 40 healthy controls were included in this study. A Chronbach's alpha of 0.83 indicated acceptable internal consistency. A paired sample t-test revealed no significant differences between WHO-5 total score at baseline and at follow-up (tn = - 0.72; df = 15; p = 0.48). The PCA provided a single factor solution that accounted for 59.74% of the variation in WHO-5. Test-retest reliability was high (r = 0.83; p < 0.001). Moderate negative correlations were observed between the WHO-5 total score, the FAST (r = - 0.46.; p < 0.001) and the HAM-D (r = - 0.68; p < 0.001), but not with the YMRS (r = - 0.07; p = 0.42). Finally, significant differences were found when comparing the WHO-5 total score between patient and healthy controls (t = 5.1; df = 147; p < 0.001).

LIMITATIONS

some limitations include the lack of a comparator scale to test for validity construct and the small sample size in the test-retest reliability CONCLUSIONS: The WHO-5 shows an acceptable reliability index and measures a unitary construct in a Spanish population of euthymic patients with BD.

Effects of venlafaxine versus lithium monotherapy on quality of life in bipolar II major depressive disorder: Findings from a double-blind randomized controlled trial

Bipolar disorder is associated with decreased quality of life, especially during depressive episodes. There are few studies that have examined whether quality of life improves following pharmacological treatments of bipolar depression. In this exploratory study, we examined the effects of antidepressant versus mood stabilizer monotherapy on quality of life ratings in bipolar II subjects during acute (12 week) treatment. Data were derived from a randomized double-blind comparison of venlafaxine (n = 65) versus lithium (n = 64) monotherapy. The Quality of Life Index (QLI) was administered at baseline (n = 126; 98%) and again at the end of treatment. We explored treatment differences in continuous changes on the QLI using last-observation carried forward. Additionally, we explored the likelihood of experiencing clinically-significant improvements as well as baseline correlates of QLI and changes in QLIe. Venlafaxine was superior to lithium in reducing symptoms of depression during acute treatment. However, there were no significant differences between treatments in QLI ratings. Changes in symptoms of depression were correlated to, but not redundant, with improvements in QLI ratings. These findings suggest that quality of life may be an important secondary outcome to target and measure as a part of comparative clinical trials of pharmacotherapy for bipolar II depression.