Elsevier

Journal of Affective Disorders

Volume 209, February 2017, Pages 147-154
Journal of Affective Disorders

Review article
The difficult lives of individuals with bipolar disorder: A review of functional outcomes and their implications for treatment

https://doi.org/10.1016/j.jad.2016.11.021Get rights and content

Highlights

  • BP patients exhibit high rates of functional impairment in all domains.

  • Subsyndromal depression and cognitive impairment are linked to the impairment.

  • Treatments for functional impairment in bipolar disorder have rarely been explored.

Abstract

Background

Most longitudinal or treatment studies in bipolar disorder have used symptomatic or syndromal status as the primary outcome variable. More recently, psychosocial functioning has been highlighted as a key domain of outcome. Patients with bipolar disorder appear to be impaired in all functional domains, although the factors that cause impairment have not been clearly specified.

Methods

This paper reviews cross-sectional and longitudinal studies on functional impairment and its relationship to symptomatic, neurocognitive, personality, and stress variables in bipolar disorder; and the implications of these relationships for defining treatment targets. 93 articles were located through comprehensive MEDLINE, SCOPUS and Web of Science searches.

Results and discussion

Functional recovery following a mood episode consistently lags behind symptomatic and syndromal recovery. Longer term functional impairment is only partly explained by the number of manic/hypomanic episodes. Depression (including subsyndromal states) and persistent neurocognitive impairment are the strongest correlates of functional impairment in bipolar disorder, with personality and psychosocial stressors playing secondary roles. Possible treatment options include: more aggressive treatment of subthreshold depressive states, pharmacotherapies that target cognition (e.g., stimulants), and adjunctive psychotherapies including cognitive remediation.

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:

  • 1.

    What is measured by these different outcome variables?

  • 2.

    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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