Social and academic premorbid adjustment domains predict different functional outcomes among youth with first episode mania

Highlights

• Childhood and adolescent adjustment predicted functioning, but not illness severity in the short to medium term after onset.

• Social adjustment predicted later interpersonal functioning while academic adjustment predicted vocational functioning.

• Premorbid adjustment may help identify subgroups that may benefit from different interventions.

Abstract

Background

Premorbid characteristics may help predict the highly variable functional and illness outcomes of young people with early stage Bipolar Disorder (BD). We sought to examine the relationships between premorbid adjustment and short to medium-term outcomes after a first treated episode of mania.

Methods

We examined the baseline and 18-month follow-up characteristics of 117 participants with first episode of mania, treated at two tertiary early intervention services in Melbourne, Australia. The baseline demographic, family history, diagnoses, comorbidity and clinical features were determined using unstructured questionnaires and structured diagnostic interviews. Premorbid adjustment was determined using the Premorbid Adjustment Scale (PAS), the components of which were identified using a principal component analysis. Eighteen-month follow-up outcome measures included the Clinical Global Impressions scale, Social and Occupational Functioning Assessment Scale and the Heinrichs’ Quality of Life Scale (QLS). Correlations and linear regressions were utilised to examine the relationships between component scores and outcomes, while controlling for baseline and follow-up confounders.

Results

The social adjustment component of the PAS correlated with the interpersonal relations (r_s = −0.46, p<0.001) domain of QLS while the academic adjustment component of the PAS correlated with the vocational functioning domain of QLS (r_s =−0.39, p = 0.004). Premorbid adjustment did not predict illness severity or objective functioning.

Limitations

Lack of information on cognition, personality factors and prodromal symptoms limited the assessment of their impact on outcomes.

Conclusions

Impairments in domains of premorbid adjustment may be early markers of persistent difficulties in social and vocational functioning and may benefit from targeted interventions.

Introduction

Bipolar Disorder (BD) is an important contributor to disability and loss of quality of life (QoL), particularly among youth (Gore et al., 2011, Whiteford et al., 2013). This may be at least partly related to the peak onset of this disorder among young people with a potential disruption of their developmental trajectories. Despite high quality care, young people with manic episodes can have variable functional and symptomatic outcomes (Gignac et al., 2015). While a significant proportion of those with first episode mania achieve syndromic and symptomatic recovery, only a minority return to their previous level of functioning (Conus et al., 2006b). Several factors may determine functional and illness outcomes among persons with BD. With respect to vocational or employment outcomes, systematic reviews and meta-analyses (Gilbert and Marwaha, 2013, Tse et al., 2014) have consistently identified predictors including cognitive functioning, depressive symptoms, years of education, and personality factors. The quality of social or interpersonal functioning has similar predictors including depressive symptoms (Pope et al., 2007, Sheets and Miller, 2010), neuroticism (Pope et al., 2007), episode severity (Siegel et al., 2015), and neurocognitive functioning (Depp et al., 2010).

Pre-onset characteristics may also determine outcomes among persons with BD; however, research on these factors is scant. Prodromal approaches attempt to characterise persons based on their premorbid symptoms (Howes et al., 2010). Examining other pre-onset domains such as premorbid social, academic and socio-sexual adjustment may be helpful to explore the subgroups with prognostic implications and where therapeutic interventions may be better targeted. Premorbid adjustment, most commonly measured using the Premorbid Adjustment Scale (PAS (Cannon-Spoor et al., 1982)) has often been noted to be better among persons with BD compared to those with schizophrenia (Cannon et al., 1997, Conus et al., 2010, Tarbox et al., 2012, Uzelac et al., 2006). One cross-sectional study even identified greater premorbid adjustment among participants with BD compared with healthy population based controls (Rietschel et al., 2009). Similarly, a normal or superior social and academic achievement was identified among those with adolescent onset BD I (Kutcher et al., 1998). Patterns of changes in premorbid adjustment may also have diagnostic specificity. In a study comparing those with schizophrenia and BD with controls, a decline in overall premorbid adjustment scores over the developmental epochs was evident only for those with schizophrenia (Paya et al., 2013). Within the domains of premorbid adjustment, academic decline may be more common than a decline in social functioning among persons with BD prior to onset of mania (Paya et al., 2013). Additionally, in another study, academic maladjustment differentiated those with BD compared with those with schizophrenia (Cannon et al., 1997), while social premorbid maladjustment did not. Thus, in all, premorbid adjustment may be a unique marker of developmental processes that separate persons with BD from those with other psychotic disorders, as well as healthy controls. Additionally, domains of premorbid adjustment may represent a simple and reliably measured marker that could delineate subgroups within persons with BD with different functional and illness outcomes.

Premorbid adjustment has been identified to be a significant predictor of overall functioning among youth and adults with BD (Gade et al., 2015, Tabares-Seisdedos et al., 2008). Similarly, among persons with BD, premorbid adjustment was associated with comorbid substance use disorders, rapid cycling and suicidality (Goldberg and Ernst, 2004). A recent report from a large cohort of participants with first episode psychotic disorders that included those with BD identified a significant continuity between premorbid social adjustment and 20-year post-onset social functioning (Velthorst et al., 2016). However, one previous study did not identify a relationship between premorbid adjustment and occupational outcomes among persons with BD (Schoeyen et al., 2013). In this latter study, the assessment of premorbid adjustment occurred later in the illness course, when there may be greater recall bias. Premorbid adjustment measured soon after the first episode of mania, particularly among young adults, is less likely to be affected by difficulties with recall. There is also a dearth of information regarding the association between specific domains of premorbid adjustment and that of post-illness functioning among persons with mania.

The aim of the current study was therefore to examine the impact of premorbid adjustment on functioning and illness severity in the short to medium term after intervention for a first episode of mania. We hypothesised that domains of premorbid adjustment will predict short-medium term functioning and severity of illness or overall symptoms. Additionally, we aimed to explore the relationship between premorbid adjustment and illness characteristics, family history, comorbidity and risks.