Review articleThe difficult lives of individuals with bipolar disorder: A review of functional outcomes and their implications for treatment
Introduction
The natural history of bipolar disorder is characterized by frequent and recurrent mood episodes. Since Kraepelin's seminal studies distinguishing manic depressive insanity (bipolar disorder) from dementia praecox (schizophrenia) (Kraepelin, 1921), it has been clear that the natural history of bipolar disorder is characterized by recurrent episodes. Despite the evolution of multiple effective mood stabilizers that prevent manias, depressions or both (Gitlin and Frye, 2012), naturalistic studies repeatedly demonstrate breakthrough episodes of mania or depression with relapse rates over 1–4 years in treated groups ranging from 40% to 60%, and 4–5 year relapse rates range from 60% to 85% (Goodwin and Jamison, 2007, Gignac et al., 2015).
Additionally, modern studies have documented moderate to severe functional impairment associated with bipolar disorder in any and all domains evaluated (Coryell et al., 1993, MacQueen et al., 2001, Keck, 2006, Judd et al., 2008, Sanchez-Moreno et al., 2009, Wingo et al., 2009). Bipolar I and II patients still have significant functional impairment after statistically controlling for the concurrent level of depression (Sanchez-Moreno et al., 2009, Coryell et al., 1989, Judd et al., 2005, Ruggero et al., 2007). Highlighting the importance of functional vs. syndromal outcomes, it has been estimated that 79% of the societal cost of bipolar disorder is due to indirect costs such as occupational impairment as opposed to direct treatment costs such as hospitalization (Dilsaver, 2011). In fact, BD is the fifth leading cause among psychiatric disorders of lost years of work (Ferrari et al., 2016).
The two methods of measuring outcome- symptomatic/syndromal vs. functional - highlight a number of questions that will be addressed in this review:
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What is measured by these different outcome variables?
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What are the relationships between syndromal or subsyndromal symptoms and different types of functional outcome in bipolar disorder?
- 3.
What are the non-symptomatic (e.g., neurocognitive) correlates of functional outcome?
- 4.
Finally, what are the implications of these findings for the pharmacological or psychosocial management of bipolar disorder?
Section snippets
Studies were identified through MEDLINE, SCOPUS, and Web of Science
The search terms included blocks pertaining to bipolar disorder (bipolar, mania, depression, hypomania, manic-depression) and functioning (impairment, psychosocial, occupational, disability, work, cognition, neurocognition, stress, remediation). The searches were limited to the period between Jan. 1, 1980 and Sept. 1, 2016. We also screened articles cited in existing reviews of the literature on functional outcomes, stress, and psychosocial interventions (Andreou and Bozikas, 2013, Cardenas et
Correlates of functional outcome in bipolar disorder
Understanding the factors associated with functional impairment is a first step towards constructing and testing treatment strategies that might improve the functioning of bipolar individuals.
Treatment implications
Given the evidence just reviewed that depressive symptoms, including subsyndromal symptoms and neurocognitive impairment are the two central factors contributing to functional impairment in bipolar disorder, treatment should focus on more aggressively addressing these two psychopathological domains and the variables that change with them. Table 1 summarizes the suggestions made above, stratified by targeted domain and treatment considerations for each.
Studies over the last twenty years have
Conclusion
Although symptomatic episodes, recurrences and mood states continue to dominate as the primary outcome variables in studies of bipolar disorder, functional outcome is increasingly being recognized as an important domain that can be reliably measured. One could argue that functional outcome is even more important than syndromal outcome since the ability to fulfill role expectations at work, at home or at school, and the quality of interpersonal relationships are often cited as the most important
Conflicts of interest
None for both authors.
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Both authors contributed to the literature review and writing of this article. They have both approved the final article.