Well-being and functioning in patients with bipolar disorder assessed using the MOS 20-ITEM short form (SF-20)

Using Immersive Virtual Reality to Enhance Social Interaction Among Older Adults: A Cross-Site Investigation

Background and Objectives

Virtual reality (VR) applications are increasingly being targeted toward older adults as a means to maintain physical and cognitive skills and to connect with others, especially during the coronavirus disease 2019 era. Our knowledge about how older adults interact with VR is limited, however, since this is an emerging area and the related research literature is still rather slim. The current study focused specifically on older adults' reactions to a social-VR environment, examining participant's views about the possibility of meaningful interactions in this format, the impacts of social-VR immersion on mood and attitude, and features of the VR environment that affected these outcomes.

Research Design and Methods

The researchers designed a novel social-VR environment with features intended to prompt conversation and collaborative problem-solving among older adults. Participants were recruited from 3 diverse geographic locations (Tallahassee, FL; Ithaca, NY; and New York City, NY), and were randomly assigned to a partner from one of the other sites for social-VR interaction. The sample consisted of 36 individuals aged 60 and older.

Results

Reactions to the social VR were quite positive. Older adults reported high levels of engagement in the environment and perceived the social VR to be enjoyable and usable. Perceived spatial presence was found to be a central driver of positive outcomes. A majority of the participants indicated a willingness to reconnect with their VR partner in the future. The data also identified important areas for improvement that were of concern to older adults, such as the use of more realistic avatars, larger controllers more suited to aging hands, and more time for training/familiarization.

Discussion and Implications

Overall, these findings suggest that VR can be an effective format for social engagement among older adults.

A comparison of symptoms of bipolar and unipolar depression in postpartum women

BACKGROUND

Distinguishing postpartum women with bipolar from unipolar depression remains challenging, particularly in obstetrical and primary care settings. The post-birth period carries the highest lifetime risk for the onset or recurrence of Bipolar Disorder (BD). Characterization of differences between unipolar and bipolar depression symptom presentation and severity is critical to differentiate the two disorders.

METHODS

We performed a secondary analysis of a study of 10,000 women screened by phone with the Edinburgh Postnatal Depression Scale at 4-6 weeks post-birth. Screen-positive mothers completed the Structured Clinical Interview for DSM-4 and those diagnosed with BD and unipolar Major Depressive Disorder (UD) were included. Depressive symptoms were assessed with the 29-item Structured Interview Guide for the Hamilton Rating Scale for Depression (SIGH-ADS).

RESULTS

The sample consisted of 728 women with UD and 272 women with BD. Women with BD had significantly elevated levels of depression severity due to the higher scores on 8 of the 29 SIGH-ADS symptoms. Compared to UD, women with BD had significantly higher rates of comorbid anxiety disorders and were twice as likely to report sexual and/or physical abuse.

LIMITATIONS

Only women who screened positive for depression were included in this analysis. Postpartum women with unstable living situations, who were hospitalized or did not respond to contact attempts did not contribute data.

CONCLUSIONS

Severity of specific symptom constellations may be a useful guide for interviewing postpartum depressed women along with the presence of anxiety disorder comorbidity and physical and/or sexual abuse.

Cognitive Behavioral Therapy for Three Patients with Bipolar II Disorder during Depressive Episodes

Bipolar II disorder is a recurrent mental health disorder characterized by alternating hypomanic and depressive episodes. Providing cognitive behavioral therapy (CBT) as an adjuvant to pharmacotherapy can reduce the recurrence rate of bipolar disorder. It has not been examined whether CBT can be started during a depressive episode in patients with bipolar II disorder; however, the use of CBT during the remission period has been demonstrated to reduce recurrence. The current study is a case report involving three Japanese patients with bipolar II disorder, who started CBT during the depressive phase after a hypomanic episode was stabilized by pharmacotherapy. All patients experienced excessively positive thinking one week apart and were able to choose behaviors that would stabilize bipolar mood by observing its precursors. After intervention, patients' bipolar mood according to the Internal State Scale (ISS) and the Beck Depression Inventory-II (BDI-II) was improved. Our findings suggested that providing CBT to patients with bipolar II disorder during depressive episodes as an adjunct to pharmacotherapy is feasible.

Prevalence of depressive, bipolar and adjustment disorders, in Quebec, Canada

BACKGROUND

The prevalence of mood disorders was estimated at 5.4% according to the latest Canadian survey. It has been suggested to use administrative data and self-reported data to optimize the estimation for mental health care in the population. Using administrative data, algorithms (combination of codes from the International Classification of Diseases) had been previously developed to identify the population with mood and anxiety disorders. However, the specific prevalence of each component of mood disorders (depressive, bipolar and adjustment disorders) are still unknown in Quebec, Canada.

OBJECTIVE

To 1) identify the population diagnosed respectively with depressive, bipolar and adjustment disorders in administrative data, and 2) provide annual prevalence estimates of each component.

METHOD

Data were extracted from the Quebec Integrated Chronic Disease Surveillance System and the entire population of Quebec (2000-2017) was included in this study (8.3 million; 2017). The prevalence of depressive, bipolar and adjustment disorders were estimated using specific algorithms.

RESULTS

The annual prevalence of depressive disorders was 3.7% in 2000-2001; it decreased to 2.8% in 2016-2017. In comparison, the prevalence of bipolar disorders was 0.8% in 2000-2001, decreasing to 0.6% in 2016-2017, and the prevalence of adjustment disorders was 1.3% in 2000-2001 and increased to 1.6% in 2016-2017.

CONCLUSION

Using specific algorithms, we observed that the trend of adjustment disorders is increasing while trends of depressive and bipolar disorders are decreasing. Further studies should assess if the related burden of care respectively follows the same trends as policy makers' allocations of resources may need to be adapted.

Influence Of Uncertainty, Depression, And Social Support On Self-Care Compliance In Hemodialysis Patients

PURPOSE

This study was conducted to examine the associations among uncertainty, depression, social support, and self-care compliance in patients undergoing hemodialysis, and to identify the factors influencing self-care compliance.

METHODS

A convenience sample of 152 patients receiving hemodialysis was selected. Data were analyzed using descriptive statistics, independent t-test, ANOVA, Pearson correlations, and hierarchical regression analysis with the SPSS 23.0 program.

RESULTS

Participants performed a moderate level of self-care consisting of factors such as knowledge of hemodialysis, dietary knowledge of hemodialysis, dietary compliance with hemodialysis, and compliance with hemodialysis order. The self-care compliance of participants undergoing hemodialysis showed a significant relationship with depression, uncertainty, and social support. The factors significantly influencing self-care compliance were social support and occupation. These variables explained 24.9% of the variance in self-care compliance.

CONCLUSION

Findings from this study confirmed that uncertainty, depression, and social support are major factors affecting self-care compliance, and that the higher the patients' uncertainty, the lower their self-care compliance. Thus, interventions should be performed to reduce uncertainty and to improve self-care through accurate information and education on disease progression and self-care.

Quality of life in euthymic bipolar patients: A systematic review and meta-analysis

BACKGROUND

Patients with bipolar disorder, even euthymic, could suffer an impairment in their quality of life compared to healthy controls. Since no previous systematic review and meta-analysis has been conducted, the aim of the current study is to conduct a systematic review and meta-analysis of cross-sectional case-controlled studies on quality of life in adult euthymic Bipolar Disorder patients.

METHODS

A systematic review and meta-analysis that followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) was conducted. Major electronic databases were searched on August 2018 to assess the variables associated with quality of life in euthymic bipolar disorder patients. After selecting case-control studies, data collection, quality assessment and subsequently statistical analysis were done.

RESULTS

66 studies were finally selected for systematic review and meta-analysis. Four different quality of life instruments were used among the different studies. Effect size analysis showed that there were significant differences in quality of life outcomes between euthymic bipolar disorder patients and healthy controls (d=-0.922; SE=0.316; 95%CI=-1.541--0.303; p=.004), with lower quality of life in the euthymic patients. Furthermore, time since euthymia explained 15.62% of variability, and age of control group explained 29.6% of variability. No other moderators were statiscally significant.

LIMITATIONS

The instruments used were heterogeneous. Moreover, the role of other clinical moderators could not be included due to the lack of this information in most of the articles.

CONCLUSIONS

Quality of life is lower in euthymic bipolar patients than in healthy controls. However, longer time in euthymia is associated with better outcomes.

Differentiating borderline personality from bipolar disorder with the Mood Disorder Questionnaire (MDQ): A replication and extension of the International Mood Network (IMN) Nosology Project

INTRODUCTION

Vöhringer et al. identified a triad of items on the Mood Disorder Questionnaire (MDQ) that best discriminated between borderline personality disorder (BPD) and bipolar disorder (BD) in a tertiary mood clinic setting [23]. The present study aimed to replicate and extend these findings by examining the performance of the triad across a range of cut-off scores and comparing the operating characteristics of the triad to the full MDQ.

METHODS

Patients presenting for treatment were assessed with the Structured Clinical Interview for DSM-IV (SCID) and the BPD module of the Structured Interview for DSM-IV Personality (SIDP-IV). The present report is based on 476 depressed patients who had a principal diagnosis of major depressive disorder or BD and who completed the MDQ.

RESULTS

Fifty-seven patients were diagnosed with BD and fifty-four patients were diagnosed with BPD. Both the triad and full MDQ significantly predicted BD diagnosis (p < .001), but the triad had optimal operating characteristics, particularly at a cut-off of two.

CONCLUSION

Within a sample of depressed patients, the MDQ triad is a better screener for BD than the full MDQ, particularly if a positive triad screen is indicated by the presence of any two items. The triad is particularly good for differentiating between BD and BPD, whereas the full MDQ does a poorer job of differential diagnosis. Future studies should administer the triad as a stand-alone scale.

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.

Quality of life in stabilized outpatients with bipolar I disorder: Associations with resilience, internalized stigma, and residual symptoms

OBJECTIVES

Improving Quality of Life (QoL) is an important objective in the treatment of bipolar disorder. The aim of the current study was to examine to which extent resilience, internalized stigma, and psychopathology are correlated to QoL.

METHODS

We recruited 60 outpatients diagnosed with bipolar I disorder according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, symptoms were quantified by the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS) and internalized stigma by the Internalized Stigma of Mental Illness (ISMI) scale. In order to assess QoL and resilience, the Berliner Lebensqualitätsprofil (BELP) and the Resilience Scale (RS-25) were used in both patients and control subjects.

RESULTS

Despite presenting with a very mild symptom level and relatively low internalized stigma, patients with bipolar I disorder indicated significantly lower QoL and resilience as compared to healthy control subjects. In patients, QoL correlated significantly with resilience, internalized stigma, and residual symptoms of depression. No significant correlations were observed between QoL and residual manic symptoms.

LIMITATIONS

The cross-sectional design and the relatively small sample size limit the generalizability of our results. Furthermore, levels of resilience and internalized stigma may change over the course of the illness and have different impacts on the long-term outcome of patients with bipolar disorder.

CONCLUSION

Our results show that QoL of patients suffering from bipolar I disorder, even when only mildly ill, is strongly associated with the degree of resilience and internalized stigma, and that particularly residual depressive symptoms have a negative impact on QoL. In addition to drug treatment, psychotherapeutic approaches should be applied to strengthen resilience, to reduce internalized stigma, and, ultimately, to improve quality of life.

Haste or Speed? Alterations in the Impact of Incentive Cues on Task Performance in Remitted and Depressed Patients With Bipolar Disorder

A variety of evidence suggests that bipolar disorder is associated with disruptions of reward related processes, although the properties, and scope of these changes are not well understood. In the present study, we aimed to address this question by examining performance of patients with bipolar disorder (30 depressed bipolar; 35 euthymic bipolar) on a motivated choice reaction time task. We compared performance with a group of healthy control individuals (n = 44) and a group of patients with unipolar depression (n = 41), who were matched on several demographic variables. The task consists of an "odd-one-out" discrimination, in the presence of a cue signaling the probability of reward on a given trial (10, 50, or 90%) given a sufficiently fast response. All groups showed similar reaction time (RT) performance, and similar shortening of RT following the presentation of a reward predictive cue. However, compared to healthy individuals, the euthymic bipolar group showed a relative increase in commission errors during the high reward compared to low condition. Further correlational analysis revealed that in the healthy control and unipolar depression groups, participants tended either to shorten RTs for the high rather than low reward cue a relatively large amount with an increase in error rate, or to shorten RTs to a lesser extent but without increasing errors to the same degree. By contrast, reward-related speeding and reward-related increase in errors were less well coupled in the bipolar groups, significantly so in the BPD group. These findings suggest that although RT performance on the present task is relatively well matched, there may be a specific failure of individuals with bipolar disorder to calibrate RT speed and accuracy in a strategic way in the presence of reward-related stimuli.

Effects of resilience on quality of life in patients with bipolar disorder

BACKGROUND

Few studies have examined the effects of resilience on quality of life (QOL) in patients with bipolar disorder (BD). Therefore, this study investigated the association between resilience and QOL in patients with BD and compared it to the relationship between resilience and QOL in healthy individuals.

METHODS

Participants were 68 euthymic patients with BD and 68 age-, sex-, and length of education-matched controls. Sociodemographic characteristics and clinical variables of the two groups were obtained using face-to-face interviews, and all participants completed the Connor-Davidson Resilience Scale, the World Health Organization QOL-Brief Form.

RESULTS

The QOL of the BD group was significantly impaired compared with that of the controls. Degree of resilience, number of depressive episodes, Clinical Global Impression scores, degree of impulsivity, and length of education were significantly correlated with QOL in the BD group. Resilience was significantly associated with overall QOL, physical subdomains of QOL, psychological subdomains of QOL, social subdomains of QOL, and environmental subdomains of QOL in the BD group, even after controlling for confounders. In the control group, resilience was significantly associated with overall QOL, the physical subdomains of QOL, psychological subdomains of QOL, and social subdomains of QOL.

LIMITATIONS

The number of participants in each group was 68, which is a relatively small sample size.

CONCLUSIONS

Resilience in patients with BD was independently and positively correlated with various areas of QOL. Various strategies to reinforce resilience in patients with BD are needed to improve the low QOL in this population.

Is history of suicidal behavior related to social support and quality of life in outpatients with bipolar I disorder?

Bipolar disorder (BD) affects the social functioning and quality of life (QoL) of its patients. This study aimed to investigate whether there is an association between social support (SS), and suicidal behavior in BD I patients compared to healthy controls; secondarily, we evaluated the influence of QoL on those variables. A total of 119 euthymic outpatients with BD I, 46 of whom had attempted suicide (SAs) and 73 who had not (non-SAs), were compared to 63 healthy controls, through the Medical Outcomes Study Social Support Scale and World Health Organization's Quality of Life Instrument. No differences were noted in SS and QoL between SAs and non-SAs. Compared to healthy controls, non-SAs showed lower values in the positive social interaction domain of SS, and the patients, as a whole, showed lower values in affectionate and positive social interaction domains of SS. Compared to healthy controls, SAs had lower values in the environmental domain of QoL, and the patients, as a whole, had lower values in the environmental, social, and psychological domains of QoL. There was positive correlation between SS and QoL. Although BD is a disabling disease, patients receive inadequate SS. Interventions that may alter the SS in these patients should be investigated.

Structural invariance of General Behavior Inventory (GBI) scores in Black and White young adults

In the United States, Black and White individuals show discrepant rates of diagnosis of bipolar disorder versus schizophrenia and antisocial personality disorder, as well as disparate access to and utilization of treatment for these disorders (e.g., Alegria, Chatterji, et al., 2008; Chrishon, Anderson, Arora, & Bailey, 2012). Such diagnostic discrepancies might stem from racially related cognitive biases in clinical judgment or from racial biases in measurements of bipolar disorder. The General Behavior Inventory (GBI) is among the most well-validated and widely used measures of bipolar mood symptoms, but the psychometric properties of the GBI have been examined primarily in predominantly White samples. In this study, we used multigroup confirmatory factor analyses (CFA) to examine the invariance of GBI scores across racial groups with a nonclinical sample. Fit was acceptable for tests of configural invariance, equal factor loadings, and equal intercepts, but not invariance of residuals. Findings indicate that GBI scores provide functionally invariant measurement of mood symptoms in both Black and White samples. The use of GBI scores may contribute consistent information to clinical assessments and could potentially reduce diagnostic discrepancies and associated differences in access to and utilization of mental health services.

The role of social relationships in bipolar disorder: a review

Social relationships and attachment are core developmental elements of human existence and survival that evolve over the lifetime of an individual. The internal and external factors that influence them include the presence of illness in the individual or in their immediate environment. The developmental aspects of attachment and social relationships have become increasingly of interest and relevance in light of early developmental epigenetic modification of gene expression patterns that may influence subsequent behavioral patterns and outcomes. This review examines extant literature on attachment and social relationships in bipolar cohorts. Despite many methodological challenges, the findings indicate that social relationships and capacity for attachment are significantly compromised in individuals with bipolar disorder compared to other mood disorders and normal controls. Though extant research is limited, research clearly points toward the importance of social relationships on the etiology, course, and consequences of bipolar disorder. We highlight a number of key considerations for future research.

Trust in Physician Scale: factor structure, reliability, validity and correlates of trust in a sample of Nigerian psychiatric outpatients

BACKGROUND

Trust is essential in the patient-physician relationship and has not been explored among Nigerian psychiatric outpatients.

OBJECTIVES

The purpose of this study was to evaluate the psychometric characteristics of the Trust in Physician Scale among a cross-sectional sample of stable Nigerian outpatients receiving treatment for psychiatric disorders.

METHODS

A consecutive sample of outpatients attending a Nigerian university teaching hospital psychiatric clinic in South-western Nigeria completed the scale (N=223). Factorial analysis, internal consistency, validity and correlates of the scale were evaluated.

RESULTS

The structure of the Trust in Physician Scale was best explained by a 2 factor construct. Cronbach's alpha was 0.68, indicating a rather modest degree of internal consistency. The 2 factors extracted also had modest internal consistencies (Cronbach's alpha 0.66 and 0.76). A fair degree of construct validity was indicated by weak positive correlation of trust with medication adherence and the numbers of previous admissions. The mean trust score was relatively high. Significant positive correlations were observed between trust scores and adherence score, number of previous admissions and the number of schizophrenic relapses.

CONCLUSION

The results suggest that despite the comparatively weak psychometric properties of the Trust in Physician Scale, it is still useful in the evaluation of trust among Nigerian psychiatric outpatients. More studies are needed to further explore and compare the properties of this scale across a wider range of patient groups in Nigeria, and to identify other factors that could interact with trust among the different patient populations in our environment.

Bipolar II disorder in patients with a current diagnosis of recurrent depression

OBJECTIVES

The prevalence of bipolar II disorder (BD-II) in Russia has never been studied. Therefore, we sought to identify patients meeting diagnostic criteria for BD-II among patients with a current diagnosis of recurrent depressive disorder (RDD) through the use of the Russian versions of the Hypomania Checklist (HCL-32) and Bipolarity Index scales for differentiating between BD-II and RDD.

METHODS

In a non-interventional diagnostic study, we selected 409 patients aged between 18 and 65 years from two medical settings with (i) a current diagnosis of RDD, (ii) an illness duration of at least three years, and (iii) at least two affective episodes. The diagnosis was based on clinical assessment and confirmed by the Russian version of the Mini International Neuropsychiatric Interview. All patients were assessed by the HCL-32, the Bipolarity Index, and the Personal and Social Performance Scale.

RESULTS

Among patients with a current diagnosis of RDD, 40.8% had a diagnosis of bipolar disorder (bipolar I disorder: 4.9%; BD-II: 35.9%). The average time lag from onset to a correct diagnosis of BD-II was 15 years and patients were treated only with antidepressants. The sensitivity of the Russian version of the HCL-32 at the optimal cutoff point (≥14.0) was 83.7%, and its specificity was 71.9%. The Bipolarity Index showed significant differences between the total scores of the patients with BD-II and RDD (31.8 versus 20.2; p < 0.0001). The optimal threshold was ≥22.0 (sensitivity 73.5%; specificity 72.3%).

CONCLUSIONS

In Russia, diagnostic errors are an important cause of the non-detection of bipolar disorder, particularly BD-II. The Russian version of the HCL-32 and the Bipolarity Index, as additional tools, could be useful for bipolarity screening.

To a broader concept of remission: rating the health-related quality of life in bipolar disorder

BACKGROUND

The relationship between remission and quality of life in bipolar disorder is incompletely understood. This study aimed to determine cut-points on the 36-item Short-Form Health Survey (SF-36) and the European Quality of Life Index (EQ-5D) that corresponded with an objective clinical measure of remission in bipolar disorder patients.

METHODS

Data from a 2-year prospective observational study of bipolar and schizoaffective patients were analysed. Concordant with previous research, the Clinical Global Impression-Bipolar Version (CGI-BP) was used as an index of remission, specifically the severity scores of 1 (normal, not at all ill) and 2 (borderline mentally ill). The mean SF-36 standardized mental component (SMC) and standardized physical component (SPC) total scores as well as the EQ-5D index score that corresponded with a CGI-BP severity score of 1 or 2 were determined.

RESULTS

The mean SF-36 score that corresponded with a CGI-BP severity score of 1 or 2, was below 50 for the SPC (49.3) and below 49 for the SMC (48.3). The mean EQ-5D score that corresponded with a CGI-BP severity score of 1 or 2 was below 0.88 (0.87).

LIMITATIONS

Although the initial sample is sufficiently large (n=240), 49 patients scored 1 and 2 on the CGI-S, of which 12 had schizoaffective disorder.

CONCLUSIONS

This study suggests that a cut-off score of ≥50 for the SPC and ≥49 for the SMC of the SF-36 and ≥0.88 for the EQ-5D index approximates a CGI-BP definition of remission.

Group cognitive behavior therapy for bipolar disorder can improve the quality of life

Bipolar disorder (BD) can have an impact on psychosocial functioning and quality of life (QoL). Several studies have shown that structured psychotherapy in conjunction with pharmacotherapy may modify the course of some disorders; however, few studies have investigated the results of group cognitive behavior therapy (G-CBT) for BD. Our objective was to evaluate the effectiveness of 14 sessions of G-CBT for BD patients, comparing this intervention plus pharmacotherapy to treatment as usual (TAU; only pharmacotherapy). Forty-one patients with BD I and II participated in this study and were randomly allocated to each group (G-CBT: N = 27; TAU: N = 14). Thirty-seven participants completed the treatment (women: N = 66.67%; mean age = 41.5 years). QoL and mood symptoms were assessed in all participants. Scores changed significantly by the end of treatment in favor of the G-CBT group. The G-CBT group presented significantly better QoL in seven of the eight sub-items assessed with the Medical Outcomes Survey SF-36 scale. At the end of treatment, the G-CBT group exhibited lower scores for mania (not statistically significant) and depression (statistically significant) as well as a reduction in the frequency and duration of mood episodes (P < 0.01). The group variable was significant for the reduction of depression scores over time. This clinical change may explain the improvement in six of the eight subscales of QoL (P < 0.05). The G-CBT group showed better QoL in absolute values in all aspects and significant improvements in nearly all subscales. These results were not observed in the TAU control group.

Quality of life in bipolar type I disorder in a one-year followup

Objectives. The aims of this study were (i) to compare Quality of Life (QOL) of patients with bipolar disorder (BD) type I to those with schizophrenia during a one-year period after hospitalization and (ii) to assess the association of different domains of QOL with severity of clinical symptoms and level of functioning in bipolar patients group. Method. A hundred and two participants were consecutively recruited before discharge from an acute hospitalization. To measure QOL as the main outcome variable, the Farsi (Persian) version of the World Health Organization's QOL Instrument Short Version (WHOQOL BREF) was used. Affective symptoms, overall functioning, and severity of mental illness were assessed as well. The assessment procedure was repeated four, eight, and 12 months after discharge. Results. No significant differences were found between patients with BD and schizophrenia on four domains of WHOQOL BREF at the baseline and the four, eight, and 12 month assessments. Within the subjects with bipolar I disorder, the most stable finding was negative association of depression severity with WHOQOL-BREF on the all four domains during repeated assessments. Conclusion. The findings suggest that persistent depressive symptoms might be the primary determinant of impaired QOL in patients with bipolar I disorder.

Syndromal and subsyndromal illness status and five-year morbidity using criteria of the International Society for Bipolar Disorders compared to alternative criteria

BACKGROUND

Subsyndromal symptoms have been recognized as relevant in the course and outcome of bipolar disorder (BD) patients. Nevertheless, their definition and cutoff points on current depression and mania scales are uncertain. The recently defined International Society for Bipolar Disorders (ISBD) operational criteria for the assessment of the course and outcome of bipolar illness have never been tested until now.

METHODS

A naturalistic longitudinal follow-up study of up to 5 years included a cohort of 317 DSM-IV-TR BD outpatients. For the first time, we assessed the proportion of visits in different affective states using the ISBD criteria. Secondarily, we compared the results with those obtained applying other cutoff points.

RESULTS

Patients were symptomatic in 39.1% (95% CI 35.3-42.9) of the visits. Subsyndromal symptoms, primarily subsyndromal depression, were present in 15.9% of patients (95% CI 13.4-18.4). No significant differences were found between bipolar I patients and bipolar II patients. There were differences in the total percentage of visits in euthymia depending on the cutoff points (p < 0.05).

CONCLUSIONS

Applying ISBD criteria, bipolar patients have significant clinical morbidity and are often symptomatic, both with threshold symptoms and with subthreshold symptoms, especially with depression. The chosen cutoff points modify the apparent results.

LIMITATIONS

The cutoff points used have not been validated. Psychopharmacologic treatments were naturalistic.

Quality of life among bipolar disorder patients misdiagnosed with major depressive disorder

OBJECTIVE

Bipolar disorder is frequently misdiagnosed as major depressive disorder (MDD). We aim to quantify the prevalence of misdiagnosed bipolar disorder among the depression population and evaluate the quality-of-life (QOL) impact of misdiagnoses.

METHOD

Data were collected from 2 self-administered, cross-sectional studies in 2003. Patients participating in The Bipolar Disorder Misdiagnosis Study (N = 1156) were previously diagnosed with depression, experienced a depressive episode within the past year, and had no previous diagnosis of bipolar disorder or schizophrenia. Patients who experienced a manic episode in the past year, based on DSM-IV criteria, were classified as misdiagnosed. Patients participating in The Bipolar Disorder Project (N = 1214) self-reported a diagnosis of bipolar disorder and were recruited through community mental health centers and support groups. Quality of life was assessed via the Psychological General Well-Being (PGWB) Index and Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8). Demographic differences between groups were controlled using linear regression models.

RESULTS

Of the diagnosed MDD sample, 14.3% met criteria for misdiagnosed bipolar disorder. When controlling for demographic differences, the PGWB overall score for the misdiag-nosed averaged 12.77 (p < .001) points lower than that of MDD patients and 9.55 (p < .001) points lower than that of diagnosed bipolar disorder patients. The average SF-8 mental component summary score for the misdiagnosed was 5.85 (p < .001) points lower than that of MDD patients and 3.18 (p = .002) points lower than that of diagnosed bipolar disorder patients.

CONCLUSION

Misdiagnosis is associated with poorer QOL than MDD or diagnosed bipolar disorder, which are recognized as having a considerable impact on QOL.

Stressful life events predict delayed functional recovery following treatment for mania in bipolar disorder

Identifying predictors of functional recovery in bipolar disorder is critical to treatment efforts to help patients re-establish premorbid levels of role adjustment following an acute manic episode. The current study examined the role of stressful life events as potential obstacles to recovery of functioning in various roles. 65 patients with bipolar I disorder participated in a longitudinal study of functional recovery following clinical recovery from a manic episode. Stressful life events were assessed as predictors of concurrent vs. delayed recovery of role functioning in 4 domains (friends, family, home duties, work/school). Despite clinical recovery, a subset of patients experienced delayed functional recovery in various role domains. Moreover, delayed functional recovery was significantly associated with presence of one or more stressors in the prior 3 months, even after controlling for mood symptoms. Presence of a stressor predicted longer time to functional recovery in life domains, up to 112 days in work/school. Interventions that provide monitoring, support, and problem-solving may be needed to help prevent or mitigate the effects of stress on functional recovery.

Reliability and validity of the Chinese Version of the Mood Disorder Questionnaire

The purpose of this study was to examine the reliability, validity, sensitivity, and specificity of the Chinese Version of the Mood Disorder Questionnaire (MDQ-C). A total of 170 patients were administered the Mini International Neuropsychological Interview and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as criterion standard by on-site psychiatrists. The Cronbach's alpha, test-retest reliability, and the content validity index of the MDQ-C were .83, .76, and .80, respectively. Factor analysis revealed that two factors, elevated mood overactivity and irritable behavior, explained 40.89% of the variance. On the basis of the sensitivity and specificity results, the optimal cutoff point was 6. The MDQ-C is an effective short and comprehensive tool with robust psychometric properties for diagnosis of bipolar disorders, specifically for patients with bipolar I.

Disability in patients with bipolar and recurrent depressive disorder in remission: a comparative study

BACKGROUND

To compare the disability among patients with bipolar disorder and recurrent depressive disorder in remission.

SETTINGS AND DESIGN

Cross-sectional study of outpatients.

MATERIALS AND METHODS

Patients in the remission phase of the illness were taken for the study. Disability assessment was done using Indian Disability Evaluation and Assessment Scale. Treatment compliance was measured using medication adherence rating scale.

STATISTICAL ANALYSIS

Between group comparison.

RESULTS

A total of 40 patients were included in the study, 25 in bipolar and 15 in recurrent depressive disorder group. There was no difference between the groups in the domain of self care. The bipolar patients had more impairment in interpersonal activities than recurrent depressive disorder (RDD) group, this difference was statistically significant (P=0.004). The bipolar patients had more impairment in communication and understanding (P=0.009) and in work (P=0.011). The mean total score for disability was more for bipolar patients (P=0.0001). The total duration of illness had significant influence on communication and understanding, work, and total disability scores. The total number of episodes significantly influenced the impairment in interpersonal activities, communication and understanding, work, and total disability scores. The impairment in self care was significantly associated with the total number of psychotic episodes (P=0.0013). No significant relation was found between treatment compliance and disability.

CONCLUSIONS

The patients with mood disorders had significant disability even during the periods of remission. The impairment was more for the bipolar patients compared with the RDD patients.

Profiles of disability among adults with bipolar spectrum disorders

BACKGROUND

Heterogeneous groups of patients with a spectrum of service needs are commonplace in mental health settings. Although comprehensive assessments are available to measure variations in service needs, numerous challenges still exist when confronting this heterogeneity and many assessments used in clinic settings are lengthy and have not been demonstrated to be consistent over time.

OBJECTIVE

The purpose of this study was to identify subgroups of persons with bipolar spectrum disorders, who have similar disability profiles, and to the extent to which the subgrouping is stable over time.

METHODS

Participants were recruited from the Continuous Improvement for Veterans in Care-Mood Disorders. Eligible patients (N = 435) were those who received inpatient or outpatient treatment for bipolar disorder at a large urban VA mental health facility in Western Pennsylvania from July 2004 through July 2006. This was a naturalistic cohort study of patients with bipolar spectrum disorders. Baseline and 1-year follow-up data were collected using face-to-face interviews and recorded abstraction. The World Health Organization Disability Assessment Scale was the primary measure used to identify subgroups within this sample.

RESULTS

Using a classification strategy called latent profile analysis, this study identified three unique subgroups that showed significant differences in various clinical measures at baseline and follow-up. The largest and most consistent subgroup differences were observed in the current bipolar symptomatology.

CONCLUSION

The classification of functional status in the present study can aid clinicians in the identification of bipolar patients, with specific impairment profiles, who may need additional intervention. Future research is needed to understand whether specific interventions targeted at these subgroups can improve the quality of care for this high-need and at-risk population.

Functional impairment in bipolar II disorder: is it as disabling as bipolar I?

INTRODUCTION

It is well established that patients with bipolar disorder experience functional impairment even in remission. Nevertheless, bipolar II disorder remains understudied because most investigations to date include only bipolar I patients or just a small sample of bipolar II patients, without explicitly comparing both subtypes of disorder. The main objective of the current report is to evaluate overall and multiple domains of functioning, specifically in bipolar II disorder compared to patients with bipolar I disorder and healthy subjects.

METHODS

233 subjects from 3 groups were compared: bipolar I patients (n=106), bipolar II patients (n=66) and healthy controls (n=61). Bipolar patients meeting criteria of remission were recruited at the Hospital Clinic of Barcelona and at different study sites in Argentina. All participants were assessed with 17-item Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS) and the Functioning Assessment Short Test (FAST). Clinical and sociodemographic data were also recorded.

RESULTS

Both subgroups of patients, bipolar I and bipolar II, showed lower overall functioning (p<0.001) and in each domain of the FAST scale (all, p<0.001) when compared to the healthy control group. Tukey post hoc test revealed that bipolar II patients scored worse in the cognitive domain compared to bipolar I patients. However, after controlling for potential confounding variables, this difference disappeared and only older age (p<0.005) and HAM-D scores (p<0.001) remained significant.

CONCLUSIONS

Our results suggest that bipolar II patients are as disabled as bipolar I patients. This may be explained, in part, because bipolar II patients experience greater lifetime residual depressive symptoms than the bipolar I subgroup, which may have particular impact on cognitive domains of functioning.

Conceptual and methodological issues in designing a randomized, controlled treatment trial for geriatric bipolar disorder: GERI-BD

AIM

This report considers the conceptual and methodological concerns confronting clinical investigators seeking to generate knowledge regarding the tolerability and benefits of pharmacotherapy in geriatric bipolar disorder (BD) patients.

METHOD

There is continuing need for evidence-based guidelines derived from randomized controlled trials that will enhance drug treatment of geriatric BD patients. Therefore, we present the complex conceptual and methodological choices encountered in designing a multisite clinical trial and the decisions reached by the investigators with the intention that study findings be pertinent to, and can facilitate, routine treatment decisions.

RESULTS

Guided by a literature review and input from peers, the tolerability and antimanic effects of lithium and valproate were judged to be the key mood stabilizers to investigate with regard to treating bipolar I disorder manic, mixed, and hypomanic states. The patient selection criteria are intended to generate a sample that not only experiences common treatment needs but also represents the variety of older patients seen in university-based clinical settings. The clinical protocol guides titration of lithium and valproate to target serum concentrations, with lower levels allowed when necessitated by limited tolerability. The protocol emphasizes initial monotherapy. However, augmentation with risperidone is permitted after three weeks when indicated by operational criteria.

CONCLUSIONS

A randomized, controlled trial that both investigates commonly prescribed mood stabilizers and maximizes patient participation can meaningfully address high-priority clinical concerns directly relevant to the routine pharmacologic treatment of geriatric BD patients.

Development and psychometric evaluation of the Bipolar Functional Status Questionnaire (BFSQ)

OBJECTIVES

Persistently impaired psychosocial functioning has been recognized in many individuals with bipolar disorder. However, existing measures of functional disability have been adapted for use in bipolar disorder based mainly on those developed for use in other conditions. The present study involved the development and validation of a new patient self-report measure specific to bipolar disorder, the Bipolar Functional Status Questionnaire (BFSQ).

METHODS

Relevant constructs were identified, evaluated, and refined through an expert advisory panel in conjunction with patient interviews. Questionnaire items were vetted through iterative patient interviews. Psychometric properties were determined based on patient responses from implementation of the proposed 33-item questionnaire in an 11-site study of 596 patients with bipolar disorder across varied phases of illness.

RESULTS

Eight constructs were identified as fundamental to functional status in bipolar disorder: cognitive function, sleep, role functioning, emotional functioning, energy/vitality, social functioning, personal management, and sexual functioning. Psychometric validation supported item reduction to a 24-item unidimensional scale, with high internal consistency (coefficient alpha's = 0.93-0.95), high test-retest reliability (intraclass correlation coefficient = 0.86, 95% confidence interval = 0.82-0.89), strong convergent validity with other functional disability measures (r's > 0.70), and highly significant discriminant validity across illness phases, with large effect sizes (Cohen's d > 0.70).

CONCLUSIONS

The BFSQ is a psychometrically sound self-report measure that can be used to effectively quantify functional status across different clinical states in patients with bipolar disorder.

Mood disorders and quality of life. A community study

BACKGROUND

The aim of the present study was to investigate the association between different quality of life sub-indexes and various mood disorders. To our knowledge, this is the first study of the relationship between quality of life and clinical conditions within the whole realm of mood disorders, past and present.

METHODS

More than 2000 persons between 18 and 65 years old from the community were studied. DSM-III-R diagnoses were assessed by the structured interview Composite International Diagnostic Interview (CIDI). Quality of life included seven aspects: Subjective well-being, Self-realization; Contact with friends, Support if ill, Absence of negative life events, Contact with family of origin; Neighbourhood quality, and a composite score; Global quality of life.

RESULTS

Reduced quality of life was observed among persons with all kinds of mood disorders the previous year. That was also the case for previous mood disorders, especially bipolar and dysthymic disorder. Those with present psychotic major depression and past bipolar disorder had the most reduced quality of life. Among the sub-indexes, subjective well-being was most affected by mood disorders, followed by negative life events and lack of social support. The relationships did not disappear when controlled for socio-demographic factors and somatic health.

LIMITATIONS

We do not know whether our results can be fully generalized to severe patient populations.

CONCLUSION

Mood disorders, current as well as in remission, are related to a number of aspects of reduced quality of life.

A prospective study of the impact of comorbid medical disease on bipolar disorder outcomes

BACKGROUND

Several studies suggest that medical comorbidity is associated with worse clinical status in bipolar disorder. It is unclear which aspect of medical comorbidity is responsible: simple disease count, risk for future morbidity, or current physical burden.

METHODS

We analyzed three years of prospective data from a randomized clinical trial of collaborative care in 306 bipolar veterans. We examined the association of clinical outcome with baseline medical comorbidity defined as: (1) simple active disease count, (2) diseases with risk for future morbidity measured with the Charlson Comorbidity Index, and (3) current physical burden measured with the SF-36 Physical Component Summary score (PCS). Bipolar outcomes were weeks in episode, mean depression score, and change in mental health burden measured by the SF-36 Mental Component Summary score (MCS).

RESULTS

The three medical comorbidity measures were not highly correlated, indicating that each conveyed novel information. Controlling for potential confounders, worse baseline PCS predicted significantly higher mean depression scores (p=0.011) and less improvement in MCS scores (p=0.0099) over three years. Simple disease count and risk for future risk did not predict worse bipolar outcomes.

LIMITATIONS

Some potential limitations include not accounting for all confounding factors, selection bias for participants, increased the likelihood of Type I error due to multiple comparisons and having a predominantly male population.

CONCLUSIONS

This long-term prospective study extends cross-sectional and retrospective research on the link between medical illness and bipolar outcomes. It is the current experience of burden of physical illness, rather than an unweighted or weighted disease count, that leads to worse bipolar outcomes.

The functional impact of subsyndromal depressive symptoms in bipolar disorder: data from STEP-BD

BACKGROUND

This report describes baseline characteristics and functional outcomes of subjects who have prospectively observed subsyndromal symptoms after a major depressive episode (MDE).

METHODS

All subjects were participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We identified subjects with at least 2 years of observation whose prior or current episode was a MDE, and who were in a stable clinical state of either recovered (no more than 2 moderate symptoms for at least 8 weeks), a MDE by DSM-IV criteria, or with continued subsyndromal symptoms. The subsyndromal group was defined a priori as 3 or more moderate affective symptoms but without meeting diagnostic criteria for major depression.

RESULTS

The final cohort included 1094 recovered, 112 subsyndromal, and 310 individuals in a MDE. The average time spent in each clinical status ranged from 120 to 132 days. The subsyndromal group was most similar to those in a MDE, differing only on the intensity of depressive symptoms and the number of work days missed due to ongoing symptoms. Reported sadness, inability to feel and lassitude were each associated with multiple measures of impairment.

LIMITATIONS

This study is limited by the cross-sectional approach to defining outcomes.

CONCLUSIONS

These findings are consistent with studies in unipolar major depression that indicate that functional impairment observed in the context of subsyndromal depressive symptoms is comparable to that of a full episode. This work underscores the need to include subsyndromal symptoms in study outcomes and to target full remission in clinical practice.

Quetiapine monotherapy in the treatment of depressive episodes of bipolar I and II disorder: Improvements in quality of life and quality of sleep

INTRODUCTION

The depressive symptoms of bipolar disorder impact health-related quality of life, quality of sleep and functioning. The BOLDER I and II trials demonstrated that quetiapine significantly improves depressive symptoms in patients with acute bipolar depression. Post-hoc analysis of the BOLDER I and II data permits a detailed investigation of the effects of quetiapine on these other measures in this patient population.

METHODS

Secondary analysis was performed on data from BOLDER I and II, which were two 8-week, double-blind, randomized, placebo-controlled studies of quetiapine at fixed doses (300 or 600 mg/day) in a total of 1051 patients with acute depressive episodes of bipolar I or II disorder. Measures included the Short-Form Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q SF) in BOLDER I and II, the Pittsburgh Sleep Quality Index (PSQI) in BOLDER I, and the Sheehan Disability Scale (SDS) in BOLDER II. Analyses of Q-LES-Q SF score changes were based on data from the combined BOLDER I and II populations, and analyses of PSQI and SDS score changes were based on BOLDER I and BOLDER II populations, respectively.

RESULTS

Assessments at day 57 by mixed-model repeated measures analysis demonstrated that quetiapine relative to placebo provided significant or numerical improvements in rating scale score on the Q-LES-Q SF (10.89 with 300 mg/day and 12.14 with 600 mg/day vs. 7.79 with placebo; p<0.001 for each quetiapine dose), PSQI (-5.34 and -6.00 vs. -3.35; p<0.001, each dose), and SDS (-7.78 and -8.25 vs. -6.49; p=0.156 and 0.054, respectively). Effect sizes at day 57 with quetiapine 300 and 600 mg/day, respectively, were 0.34 and 0.46 for Q-LES-Q SF, 0.59 and 0.79 for PSQI, and 0.17 and 0.23 for SDS. Improvements were evident at first post-baseline assessment on day 29 and were consistent over the majority of rating scale domains. Quetiapine was generally well tolerated and most adverse events were of mild to moderate intensity.

CONCLUSIONS

Quetiapine monotherapy is effective in improving impairment in important aspects of life that accompany improvements in depressive symptoms in patients with acute bipolar depression.

Bipolar disorders and quality of life: the impact of attention deficit/hyperactivity disorder and substance abuse in euthymic patients

Patients with bipolar disorders (BPD) display high rates of comorbidities, especially substance abuse (20-40%) and attention deficit/hyperactivity disorder (ADHD) (6%-20%). However, there are virtually no data evaluating the role of current ADHD on the global functioning of patients with BPD. The recent literature suggests that impairments in quality of life are a key prognostic feature for predicting the long course of BPD. The aim of this study was to investigate the intrinsic impact of adult ADHD and substance abuse in patients with BPD on levels of social adaptation, functioning and vitality. Seventy-three outpatients with BPD I or II, all euthymic and being treated with mood stabilizers, were evaluated using the following measures: 1) the Diagnostic Interview of Genetics Study for DSM-IV criteria; 2) the ADHD Self-Report Scale (ASRS) (screening of adult ADHD); 3) measures of quality of life: social adaptation (Social Adjustment Scale Self-Report (SAS-SR)), well-being (Short Form 36 (SF-36) Health Survey), and the Brief Psychiatric Rating Scale. In this clinical sample, 30% met the ADHD criteria and 22% were substance abusers. The results showed that the presence of ADHD in BPD patients significantly predicted a low social functioning and adaptation by comparison with BPD patients without ADHD. By contrast, we failed to detect a significant impact of substance abuse on those functional outcomes. This is the first step towards improved screening for comorbidities and an understanding of their crucial role in the prognosis of the disorder, as well as in defining new multilevel therapeutic strategies.

Burden of bipolar depression: impact of disorder and medications on quality of life

Bipolar disorder is a complex, chronic psychiatric condition characterized by recurring episodes of depressive illness and mania or hypomania. Although the manic or hypomanic episodes define the disorder, recent research has shown that depressive symptoms predominate over manic symptoms in the majority of patients, and that bipolar depression accounts for much of the significant morbidity and mortality associated with bipolar disorder. Given these findings, there has been a recent upsurge of interest in furthering our understanding of the burden of depression in bipolar disorder. At the same time, increasing scientific attention is now being paid to expanding the measurement of outcome in bipolar disorder to encompass broader indicators of response, one of which is the assessment of quality of life (QOL). In this review, we provide a summary of the current knowledge about QOL in the depressive phase of bipolar disorder, and the effects of pharmacological treatment interventions for bipolar disorder upon QOL. It appears that QOL is poorer in bipolar disorder than in other mood disorders and anxiety disorders, but that schizophrenia might compromise QOL more severely than bipolar disorder. Existing data also suggest that, for patients with bipolar disorder, QOL is negatively associated with depression, both as a cross-sectional mood state and perhaps also as a feature of the patient's course. Despite its clinical and public health importance, bipolar depression has only recently started to receive the attention it warrants in clinical trials, and many important questions about its optimal pharmacological management remain to be answered. There is also a paucity of information about the impact of pharmacological interventions on QOL in bipolar depression. To our knowledge, only two clinical trials to date have specifically examined the impact of medications on QOL in patients with bipolar depression. A small number of other studies have examined the effects of depressive symptoms on QOL in patients who are experiencing manic or mixed episodes. Nonetheless, QOL appears to be a meaningful and important indicator of outcome and recovery in this patient population, and one that warrants further scientific interest and energy.

Quality of life in bipolar disorder patients: a comparison with a general population sample

OBJECTIVES

To compare the Quality of Life (QoL) of bipolar disorder (BD) patients with that of the general population; and, within the BD patients, to find the demographic and clinical variables associated with low QoL, controlling for the effects of potential confounders.

METHODS

Based on the 25th percentile of the physical (PCS) and the mental (MCS) component scores (PCS <53 and MCS < 50, respectively) of the Medical Outcomes Survey 36-item Short-Form Health-Survey (SF-36) of a general population representative sample (n = 1,210), we compared by logistic regression the QoL of 48 euthymic and 60 non-euthymic BD outpatients and the general population. Within BD patients, we analyzed the clinical and course-of-illness variables associated with low physical and mental QoL, including manic and depressive symptoms and consumption of addictive substances; in addition, we calculated the partial correlation of the different variables with the dimensional PCS and MCS through multiple linear regression.

RESULTS

Low physical QoL was significantly more frequent among both euthymic [odds ratio (OR) = 3.5; 95% confidence interval (CI): 1.9-6.5] and non-euthymic (OR = 4.0; 95% CI: 2.3-7.0) BD patients than in the general population; the respective values for low mental QoL were OR = 2.2; 95% CI: 1.2-4.0 and OR = 8.5; 95% CI: 4.6-15.7. Low mental QoL was more frequent among non-euthymic than euthymic BD patients (OR = 3.9; 95% CI: 1.6-9.1). Within BD patients, low mental QoL was associated with the length of illness (or early onset), the presence of depressive symptoms, nicotine dependence and the lack of social support.

CONCLUSIONS

Among the BD patients, who experience lower physical and mental QoL even in a euthymic period, the optimal control of depressive symptoms as well as the availability of social support may enhance their well-being.

Experience of subjective symptoms in euthymic patients with bipolar disorder

Bipolar patients often experience subjective symptoms even if they do not have active psychotic symptoms in their euthymic state. Most studies about subjective symptoms are conducted in schizophrenia, and there are few studies involving bipolar patients. We examined the nature of the subjective symptoms of bipolar patients in their euthymic state, and we also compared it to that of schizophrenia and normal control. Thirty bipolar patients, 25 patients with schizophrenia, and 21 normal control subjects were included. Subjective symptoms were assessed using the Korean version of the Frankfurter Beschwerde Fragebogen (K-FBF) and the Symptom Check List 90-R (SCL90-R). Euthymic state was confirmed by assessing objective psychopathology with the Positive and Negative Syndrome scale of Schizophrenia (PANSS), the Young Mania Rating Scale (YMRS), and the Montgomery Asberg Depression Rating Scale (MADRS). K-FBF score was significantly higher in bipolar patients than in normal controls, but similar to that in schizophrenia patients (F=5.86, p=0.004, R2=2033.6). In contrast, SCL90-R scores did not differ significantly among the three groups. Euthymic bipolar patients experience subjective symptoms that are more confined to cognitive domain. This finding supports the hypothesis that subtle cognitive impairments persists in euthymic bipolar patients.

Impact of anxiety disorder comorbidity on quality of life in euthymic bipolar disorder patients: differences between bipolar I and II subtypes

BACKGROUND

Few studies investigated the impact of anxiety disorder comorbidity on health-related quality of life (HRQoL) of bipolar patients and none examined bipolar subtypes differences. The aim of the study was 1) to determine comorbidity rates for anxiety disorders in euthymic bipolar subjects, comparing bipolar type I and II disorders (BDI and BDII), and 2) to compare within each group HRQoL measures in subjects with and without anxiety comorbidity.

METHODS

Comorbidity was evaluated through the SCID-I; HRQoL was assessed using the 36-Item Short-Form Health Survey (SF-36). All subjects were euthymic since at least 2 months, as confirmed by a HAM-D <8 and a YMRS <6. A comparison was made for SF-36 scores between subjects (all bipolars, BDI and BDII) with and without anxiety disorders.

RESULTS

105 patients were enrolled: 44 with BDI and 61 with BDII. Current and lifetime anxiety disorders comorbidities were 32.4% and 41.0% for all bipolars, 31.8% and 40.9% for BDI and 32.8% and 41.0% for BDII. BDI patients differed in several SF-36 domains from BDII subjects, which reported a poorer HRQoL. A current and lifetime comorbid anxiety disorder was associated with a poorer HRQoL considering all bipolars; when examining separately BDI and II subjects, however, the deleterious effect was restricted to BDI patients.

LIMITATIONS

The cross-sectional assessment of HRQoL, the generic instrument used (SF-36) and the small sample size.

CONCLUSIONS

Our study confirms the high comorbidity rates for anxiety disorders in bipolar subjects and provides evidence that anxiety comorbidity impacts HRQoL in subjects with BDI and not BDII.

A cross-sectional comparison of disability and quality of life in euthymic patients with bipolar affective or recurrent depressive disorder with and without comorbid chronic medical illness

BACKGROUND

There are major health care implications of quality of life (QOL) and disability in long-standing disorders such as bipolar affective disorder (BAD) and recurrent depressive disorder (RDD).

OBJECTIVES

To compare the inter-episode QOL and disability in patients with the diagnosis of BAD or RDD in remission with and without comorbid chronic medical illness.

MATERIALS AND METHODS

Cross-sectional assessments of the four groups were carried out. Euthymic bipolar or RDD subjects with chronic comorbid medical illnesses were included in the study. QOL assessment was carried out using the World Health Organization (WHO)-QOL - Bref Kannada version. Disability was assessed using the Schedule for Assessment of Psychiatric Disability (SAPD), which is an Indian modification of the WHO Disability Assessment Schedule-II.

RESULTS

Eighty patients were enrolled into the study (20 patients in each group). The mean disability scores in the BAD group was significantly more in 'social role' (P = 0.038), and in the RDD group it was more in 'home atmosphere' (P = 0.001) in the two groups (n = 40) with chronic comorbid medical illness. In the other group without comorbid chronic medical illness (n = 40), the BAD group had significantly more disability in 'overall behavior' (P = 0.002) and 'social role' (P = 0.001), and the RDD group had significantly more disability in 'assets and/or liabilities' (P = 0.004) and 'home atmosphere' (P = 0.001). The QOL measures did not differ significantly between the two disorders.

CONCLUSIONS

The presence of chronic comorbid medical illness did not cause a difference in the QOL between the two groups in periods of euthymia. However, disability measures differed significantly between the groups.

Psychosocial impairment associated with bipolar II disorder

BACKGROUND

Significant research has looked at the psychosocial impairment associated with bipolar I disorder and major depressive disorder. Far less is known about the impact of bipolar II disorder. The present study assessed the social and work impairment associated with bipolar II disorder and whether these are more or less severe than those associated with bipolar I disorder or major depressive disorder.

METHODS

Psychiatric outpatients with bipolar II disorder (n=89), bipolar I disorder (n=45) and major depressive disorder (n=1251) were assessed cross-sectionally by highly trained raters using semi-structured interviews. Participants were in a major depressive episode. Groups were compared on a series of indicators of psychosocial functioning.

RESULTS

Bipolar I and II disorder were associated with greater absenteeism from work due to psychopathology compared to major depressive disorder. The bipolar disorders also had higher rates of hospitalization and suicide attempts. Bipolar II disorder had fewer hospitalization than bipolar I disorder which may have led to slightly less severe work impairment. Both conditions had similar rates of serious suicide attempts.

LIMITATIONS

The study was cross-sectional and retrospective. Furthermore, the sample consisted of outpatients seeking treatment, limiting generalizability to other settings.

CONCLUSION

Bipolar II disorder is associated with serious work impairment and a high number of serious suicide attempts. The level of impairment is more similar than it is different from that associated with bipolar I disorder. Clinicians would be mistaken to presume that the "softer" bipolar spectrum, specifically bipolar II disorder, is less impairing than bipolar I disorder.

Health-related quality of life and functioning in remitted bipolar I outpatients

The aim of this study was to characterize the health-related quality of life (HR-QOL) and functioning in 90 bipolar I remitted outpatients. According to Diagnostic and Statistical Manual of Mental Disorders IV remission specifiers, patients were categorized into 4 groups: group 1, fully remitted; group 2, less than 2 months remitted; group 3, with persisting manic symptoms; group 4, with persisting depressive symptoms. The severity of psychopathology was evaluated by using the Bech-Rafaelsen Mania-Melancholia Scale. The HR-QOL, functioning, and insight were assessed via the medical outcomes study 36-item short form, the global assessment of functioning scale, and the scale to assess unawareness of mental disorder, respectively. Fully remitted patients reported the highest scores in almost all domains of medical outcomes study 36-item short form, and had significantly higher scores on physical functioning, general health, social functioning, and mental health compared to patients with persisting depressive symptoms. Furthermore, patients with persisting manic symptoms reported significantly higher scores on general health, vitality and mental health than the group with persisting depressive symptoms. In contrast, the global assessment of functioning scale score differed among the 4 groups, with fully remitted patients reporting higher, although not statistically significant, scores than the other groups. Our data suggest that the persistence of depressive or manic symptoms seem to affect self-report measures of HR-QOL. An affectively biased cognition may explain the gap between patient's perception of functioning and estimated functional adjustment, as assessed by clinicians.

The public health aspects of bipolar disorder in children and adolescents

Bipolar disorder in children and adolescents is a major public health problem associated with significant functional impairment. Similar to adults with bipolar disorder, children and adolescents are at increased risk for substance-related disorders, weight problems, and impaired social support systems. Substance-related problems complicate treatment course. They often follow the onset of bipolar disorder; thus, the opportunity for prevention and/or early intervention exists. Evidence supports an association between mood disorders and weight gain. Psychotropic agents to treat bipolar disorder, particularly some second-generation antipsychotics, may be associated with weight gain. Obesity is associated with worse outcomes in bipolar disorder, so prevention of weight gain is clinically important. Environmental factors may contribute to relapse, so interventions to optimize social support systems are being evaluated. Pediatric bipolar disorder requires comprehensive management to achieve optimal outcome. Further research to study modifiable factors that contribute to its morbidity and chronicity is needed.

Disability and its treatment in bipolar disorder patients

Bipolar disorders (BPD) are major, life-long psychiatric illnesses found in 2-5% of the population. Prognosis for BPD was once considered relatively favorable, but contemporary findings suggest that disability and poor outcomes are prevalent, despite major therapeutic advances. Syndromal recovery from acute episodes of mania or bipolar major depression is achieved in as many as 90% of patients given modern treatments, but full symptomatic recovery is achieved slowly, and residual symptoms of fluctuating severity and functional impact are the rule. Depressive-dysthymic-dysphoric morbidity continues in more than 30% of weeks in follow-up from initial episodes as well as later in the illness-course. As few as 1/3 of BPD patients achieve full social and occupational functional recovery to their own premorbid levels. Pharmacotherapy, though the accepted first-line treatment for BPD patients, is insufficient by itself, encouraging development of adjunctive psychological treatments and rehabilitative efforts to further limit morbidity and disability. Interpersonal, cognitive-behavioral, and psychoeducational therapies all show promise for improving symptomatic and functional outcomes. Much less is known about how these and more specific rehabilitative interventions might improve vocational functioning in BPD patients.

[Psychoeducational and cognitive behavioral treatments of bipolar disorder]

Bipolar disorder is a severe mood disorder characterized by recurrence of mania and depression. Despite the use of mood stabilizers, a significant proportion of bipolar patients experience relapse, psychosocial impairment and persistent symptoms. A significant part of patients show poor adhesion to the pharmacological treatment. This article aims to provide an overview of research focusing on psychoeducational and cognitive-behavioral treatment (CBT) of bipolar patients.

METHOD

Studies were identified through Medline searches between 1971 and 2005.

RESULTS

Studies on bipolar patients suggest that psychoeducational interventions may improve treatment adherence, illness knowledge, ability to cope with early manic symptoms and tend to reduce the risk of manic relapses. CBT tends to diminish depressive symptoms, improve treatment adherence and reduce the risk of depressive and manic relapses. Most psychoeducational and CBT studies share a common medical model of the illness, thereby making clear distinctions of impact of each intervention difficult. Few studies focused on patients with problems with mood stabilizers adherence. It is now important to develop specific interventions for those patients.

CONCLUSION

According to these studies, bipolar patients are likely to benefit from psychoeducational or CBT interventions added to usual pharmacotherapy. In order to overcome limitations of existing research, future studies should adjust for the effect of pharmacological treatment, the type and severity of psychopathology at baseline, the acceptance of and the adaptability to the illness and it's awareness.

Burden of illness in bipolar depression

Bipolar depression is the underrecognized and unappreciated phase of bipolar disorder. Nevertheless, bipolar depression is responsible for much of the morbidity and mortality associated with the disorder. Depressive symptoms are far more prevalent than hypomanic or manic symptoms in bipolar patients, and they are associated with a heavier burden of illness, including reduced functioning, increased risk of suicidal acts, and high economic costs. Because most patients with bipolar disorder present with depression, misdiagnoses of major depressive disorder are common, even typical. Comorbid psychiatric disorders are also prevalent and may obscure the diagnosis and complicate treatment strategies. Depressed patients should be carefully assessed for manic or hypomanic symptoms to help reveal possible bipolar disorder. In addition to evaluation of psychiatric symptoms, a close examination of family history, course of illness, and treatment response will aid the clinician in making an accurate diagnosis. Treatment of acute depression in bipolar patients may require therapy combining agents such as lithium, divalproex, lamotrigine, carbamazepine, and atypical antipsychotics or using such agents in combination with an anti-depressant. Olanzapine/fluoxetine combination is the only medication currently approved for the treatment of bipolar depression. Antidepressant monotherapy should not be used, because there is evidence that such treatment increases the risk of switching into mania/hypomania and could induce treatment-refractory conditions such as mixed or rapid-cycling states. Maintenance therapy will be required by most patients, since discontinuation of mood stabilizers or antidepressants frequently leads to relapses in depressive symptoms. Prompt diagnosis and the use of specific therapeutic agents with evidence of efficacy may help reduce the disease burden associated with bipolar depression.