Development of the International Classification of Functioning, Disability and Health core sets for bipolar disorders: results of an international consensus process

Clinical and personal predictors of functioning in affective disorders: Exploratory results from baseline and 6-month follow-up of a randomised controlled trial

Comprehensive knowledge of factors causing and sustaining functional impairment in patients with affective disorders is warranted. The aim is to investigate associations between clinical factors (such as affective symptoms) and personal factors (such as personality traits, coping strategies, and childhood trauma experiences) on functioning and improvement of functioning in patients with affective disorders. This exploratory study includes data from 103 patients with bipolar disorder and unipolar depressive disorder. Clinician-rated functioning was assessed at baseline using the Functioning Assessment Short Test (FAST), and performance-based functioning was assessed at baseline and 6-month follow-up using the Assessment of Motor and Process Skills (AMPS). Data on clinical and personal factors were collected at baseline. Personal factors were measured by the Eysenck Personality Inventory (EPQ), Coping Inventory for Stressful Situations (CISS) and Childhood Trauma Questionnaire (CTQ). Pearson correlations and multiple linear regression models were used to analyse the association of clinical and personal factors with baseline functioning (FAST) and to identify predictors of improvement in functioning (AMPS) from baseline to follow-up. At baseline, greater depressive symptom severity, the personality trait neuroticism, emotional coping, and childhood trauma all correlated with poorer functioning (higher FAST scores). In multiple linear regression models, depression severity, emotional coping and childhood trauma were significant predictors of poorer functioning. More childhood trauma was a predictor of less functional improvement measured by AMPS at 6-month follow-up. In conclusion, maladaptive coping styles and depressive symptoms contribute to functional impairment in patients with affective disorders, while childhood trauma has a negative impact on long-term functional outcomes.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Neural basis of memory impairments and relation to functional disability in fully or partially remitted patients with affective disorders

Bipolar disorder (BD) and major depressive disorder (MDD) are associated with cognitive and functional impairment. Cognitive impairment is often associated with dorsal prefrontal cortex (dPFC) hypo-activity, but the neuronal correlates of functional disability is largely unknown. In this study, 91 patients with affective disorders in full or partial remission (BD, n = 67; MDD, n = 24) with objectively verified cognitive impairment and substantial functional disability underwent neuropsychological assessment and functional magnetic resonance imaging (fMRI) scan during which they completed a strategic picture-encoding task. For comparison, 36 matched healthy controls underwent an identical test protocol. Patients showed encoding-related hypo-activity in the dPFC compared to controls. In patients, lower right dlPFC activity was associated with poorer overall functioning and more antipsychotic drug use. In conclusion, memory impairments were underpinned by failure to recruit the dPFC during task performance which was associated with impaired functioning in fully or partially remitted patients with affective disorders. This aberrant neurocircuitry activity has implications for the design of future pro-cognitive interventions that aim to improve not only cognition but also real-world functioning.

Affective disorders: eliminate WArning signs and REstore functioning-AWARE-a randomised controlled multimodule intervention study, presentation of design and intervention

INTRODUCTION

Affective disorders are associated with impaired overall functioning and quality of life (QoL). Despite different medical and psychological treatment options, the prognosis remains largely unchanged. Consequently, the field needs new intervention strategies especially targeting patient groups with impaired functioning. This study aims to improve functioning and QoL in patients with affective disorders using a comprehensive 360° intervention.

METHODS AND ANALYSIS

Affective disorders: eliminate WArning signs And REstore (AWARE) functioning is a randomised, controlled, parallel-group design study. Participants will be 120 outpatients, men or women, aged 18-65 years, with a diagnosis of bipolar disorder or major depressive disorder. Inclusion requires an objectively rated impaired functioning defined as a score ≥11 according to the Functioning Assessment Short Test. Participants will be randomised to 6-month AWARE intervention or treatment as usual (TAU). The AWARE intervention is a 360° multimodal intervention based on the International Classification of Functioning Brief Core Set for bipolar and unipolar disorder targeting functioning.The primary outcome is improvement of observation-based activities of daily living (ADL) ability using Assessment of Motor and Process Skills. Secondary outcomes are changes from baseline to endpoint in functioning, QoL, stress, cognition and physical health.Our hypothesis is that the AWARE treatment in comparison with TAU will improve observed ability to perform ADL, patients self-perceived level of functioning and QoL.Status: currently recruiting patients.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The Regional Ethics Committee in the Capital Region of Denmark. All patients will be provided oral and written information about the trial before informed consent is obtained. The study results will be disseminated by peer-review publications. If the present AWARE intervention shows beneficial effects, the goal is to use it as a template for future interventions addressing disability in patients with affective disorders as well as for patients within other diagnostic categories.

TRIAL REGISTRATION NUMBER

NCT04701827; Clinicaltrials.gov.

Content Validation of a Practice-Based Work Capacity Assessment Instrument Using ICF Core Sets

PURPOSE

A shift from providing long-term disability benefits to promoting work reintegration of people with remaining work capacity in many countries requires new instruments for work capacity assessments. Recently, a practice-based instrument addressing biopsychosocial aspects of functioning, the Social Medical Work Capacity instrument (SMWC), was developed. Our aim was to examine the content validity of the SMWC using ICF core sets.

METHODS

First, we conducted a systematic search to identify relevant ICF core sets for the working age population. Second the content of these core sets were mapped to assess the relevance and comprehensiveness of the SMWC. Next, we compared the content of the SMWC with the ICF-core sets.

RESULTS

Two work-related core sets and 31 disease-specific core sets were identified. The SMWC and the two work-related core sets overlap on 47 categories. Compared to the work-related core sets, the Body Functions and Activities and Participation are well represented in the new instrument, while the component Environmental factors is under-represented. Compared to the disease-specific core sets, items related to the social and domestic environmental factors are under-represented, while the SMWC included work-related factors complementary to the ICF.

CONCLUSION

The SMWC content seems relevant, but could be more comprehensive for the purpose of individual work capacity assessments. To improve assessing relevant biopsychosocial aspects, it is recommended to extend the instrument by adding personal and environmental (work- and social-related) factors as well as a more tailored use of the SMWC for assessing work capacity of persons with specific diseases or underlying illness.

Development of a core outcome set for use in community-based bipolar trials-A qualitative study and modified Delphi

Background

A core outcome set (COS) is a standardised collection of outcomes to be collected and reported in all trials within a research area. A COS can reduce reporting bias and facilitate evidence synthesis. This is currently unavailable for use in community-based bipolar trials. This research aimed to develop such a COS, with input from a full range of stakeholders.

Methods

A co-production approach was used throughout. A longlist of outcomes was derived from focus groups with people with a bipolar diagnosis and carers, interviews with healthcare professionals and a rapid review of outcomes listed in bipolar trials on the Cochrane database. An expert panel with personal and/or professional experience of bipolar participated in a modified Delphi process and the COS was finalised at a consensus meeting.

Results

Fifty participants rated the importance of each outcome. Sixty-six outcomes were included in Round 1 of the questionnaire; 13 outcomes were added by Round 1 participants and were rated in Round 2. Seventy-six percent of participants (n = 38) returned to Round 2 and 60 outcomes, including 4 outcomes added by participants in Round 1, received a rating of 7–9 by >70% and 1–3 by <25% of the sample. Fourteen participants finalised a COS containing 11 outcomes at the consensus meeting: personal recovery; connectedness; clinical recovery of bipolar symptoms; mental health and wellbeing; physical health; self-monitoring and management; medication effects; quality of life; service outcomes; experience of care; and use of coercion.

Conclusions

This COS is recommended for use in community-based bipolar trials to ensure stakeholder-relevant outcomes, facilitate data synthesis, and transparent reporting. The COS includes guidance notes for each outcome to allow the identification of suitable measurement instruments. Further validation is recommended for use with a wide range of communities and to achieve standardised measurement.

Patient-reported outcome measures for life participation in kidney transplantation: A systematic review

For many patients with end-stage kidney disease, transplantation improves survival and quality of life compared with dialysis. However, complications and side effects in kidney transplant recipients can limit their ability to participate in activities of daily living including work, study, and recreational activities. The aim of this study was to identify the characteristics, content, and psychometric properties of the outcome measures used to assess life participation in kidney transplant recipients. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018 for all studies that reported life participation in kidney transplant recipients. Two authors identified instruments measuring life participation and reviewed for characteristics. In total, 230 studies were included: 19 (8%) randomized trials, 17 (7%) nonrandomized trials, and 194 (85%) observational studies. Across these studies, we identified 29 different measures that were used to assess life participation. Twelve (41%) measures specifically assessed aspects of life participation (eg, disability assessment, daily activities of living), while 17 (59%) assessed other constructs (eg, quality of life) that included questions on life participation. Validation data to support the use of these measures in kidney transplant recipients were available for only 7 measures. A wide range of measures have been used to assess life participation in kidney transplant recipients, but validation data supporting the use of these measures in this population are sparse. A content relevant and validated measure to improve the consistency and accuracy of measuring life participation in research may inform strategies for transplant recipients to be better able to engage in their life activities.

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

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

Thresholds for severity, remission and recovery using the functioning assessment short test (FAST) in bipolar disorder

BACKGROUND

Despite its importance, no distinction between none, mild, moderate and severe functional impairment is available. Categorization of functional impairment could help to better assess randomized controlled trials (RCT) and to study the correlates of functional impairment according to severity. The Functional Assessment Short Test (FAST) is one of the most widely used measures of functional impairment in bipolar disorder and related conditions, but to date no severity cut-offs have been determined for their use in clinical research and practice.

METHOD

FAST and Global Functioning Assessment (GAF) ratings from 65 euthymic outpatients with bipolar disorder at the Hospital Clínic in Barcelona were analyzed. A linear regression was computed using the FAST as the independent variable and the GAF as the dependent variable. Cut-offs scores for the FAST were estimated taking into account the GAF scores as a reference.

RESULTS

Linear regression analysis with GAF scores as the dependent variable yielded the following equation: GAF _score= 91,41-1,031 * FAST _score. The cut-off scores for the FAST scale derived from this equation were as follows: scores from 0 to 11 included patients with no impairment. Scores from 12 to 20, represented the category of mild impairment. Moderate impairment comprised scores from 21 to 40. Finally, scores above 40 represent severe functional impairment. Further, the 4 × 4 cross-tabulation resulted in a significant association of FAST and GAF severity gradation: (Chi²= 95,095; df = 9; p < 0,001). Chance-corrected agreement was κ = 0,65 (p < 0.001).

LIMITATIONS

In the absence of a better alternative, the GAF, a broad clinical measure, was used as gold standard for establishing FAST categories according to severity.

CONCLUSION

The categorization of functional impairment in four categories based on empirical data shows that 12, 20 and 40 represent clinically meaningful cut-offs of the FAST for mild, moderate, and severe functional impairment and for functional recovery, remission, and improvement. The proposed categories are suitable to be further implemented in clinical studies and RCTs.

Standardised assessment of functioning in ADHD: consensus on the ICF Core Sets for ADHD

Attention-deficit/hyperactivity disorder (ADHD) is associated with significant impairments in social, educational, and occupational functioning, as well as specific strengths. Currently, there is no internationally accepted standard to assess the functioning of individuals with ADHD. WHO's International Classification of Functioning, Disability and Health-child and youth version (ICF) can serve as a conceptual basis for such a standard. The objective of this study is to develop a comprehensive, a common brief, and three age-appropriate brief ICF Core Sets for ADHD. Using a standardised methodology, four international preparatory studies generated 132 second-level ICF candidate categories that served as the basis for developing ADHD Core Sets. Using these categories and following an iterative consensus process, 20 ADHD experts from nine professional disciplines and representing all six WHO regions selected the most relevant categories to constitute the ADHD Core Sets. The consensus process resulted in 72 second-level ICF categories forming the comprehensive ICF Core Set-these represented 8 body functions, 35 activities and participation, and 29 environmental categories. A Common Brief Core Set that included 38 categories was also defined. Age-specific brief Core Sets included a 47 category preschool version for 0-5 years old, a 55 category school-age version for 6-16 years old, and a 52 category version for older adolescents and adults 17 years old and above. The ICF Core Sets for ADHD mark a milestone toward an internationally standardised functional assessment of ADHD across the lifespan, and across educational, administrative, clinical, and research settings.

The Gestalt of functioning in autism spectrum disorder: Results of the international conference to develop final consensus International Classification of Functioning, Disability and Health core sets

Autism spectrum disorder is associated with diverse social, educational, and occupational challenges. To date, no standardized, internationally accepted tools exist to assess autism spectrum disorder–related functioning. World Health Organization’s International Classification of Functioning, Disability and Health can serve as foundation for developing such tools. This study aimed to identify a comprehensive, a common brief, and three age-appropriate brief autism spectrum disorder Core Sets. Four international preparatory studies yielded in total 164 second-level International Classification of Functioning, Disability and Health candidate categories. Based on this evidence, 20 international autism spectrum disorder experts applied an established iterative decision-making consensus process to select from the candidate categories the most relevant ones to constitute the autism spectrum disorder Core Sets. The consensus process generated 111 second-level International Classification of Functioning, Disability and Health categories in the Comprehensive Core Set for autism spectrum disorder—one body structure, 20 body functions, 59 activities and participation categories, and 31 environmental factors. The Common Brief Core Set comprised 60 categories, while the age-appropriate core sets included 73 categories in the preschool version (0- to 5-year-old children), 81 in the school-age version (6- to 16-year-old children and adolescents), and 79 in the older adolescent and adult version (⩾17-year-old individuals). The autism spectrum disorder Core Sets mark a milestone toward the standardized assessment of autism spectrum disorder–related functioning in educational, administrative, clinical, and research settings.

Beyond diagnosis: the Core Sets for persons with schizophrenia based on the World Health Organization's International Classification of Functioning, Disability, and Health

PURPOSE

Based on the International Classification of Functioning, Disability and Health (ICF), this paper presents the results of the process to develop the Comprehensive and Brief Core Sets for schizophrenia that allow to comprehensively describe functioning in persons with schizophrenia.

METHODS

Twenty health professionals from diverse backgrounds participated in a formal and iterative decision-making process during an international consensus conference to develop these Core Sets. The conference was carried out based on evidence gathered from four preparatory studies (systematic literature review, qualitative study, expert survey, and empirical study). The first step of this decision-making and consensus process comprised of discussions and voting in working groups and plenary sessions to develop the comprehensive version. The categories of the Comprehensive ICF Core Set for schizophrenia served as the basis for the second step -a ranking and cutoff procedure to decide on the brief version.

RESULTS

Of the 184 candidate categories identified in the preparatory studies, 97 categories were included in the Comprehensive Core Set for schizophrenia. A total of 25 categories were selected to constitute the Brief Core Set.

CONCLUSIONS

The formal decision-making and consensus process integrating evidence from four preparatory studies and expert opinion led to the first version of the Core Sets for schizophrenia. Comprehensive and Brief Core Sets for schizophrenia may provide a common language among different health professionals and researchers, and a basic international standard of what to measure, report, and assess the functioning of persons with schizophrenia. Implications for rehabilitation Schizophrenia is a chronic mental disorder that has a tremendous impact on functioning and daily life of persons living with the disorder. The International Classification of Functioning, Disability and Health (ICF) offers an internationally recognized standard for describing the functioning status of these individuals. The Core Sets for schizophrenia have potential use in supporting rehabilitation practice such as for planning mental health services and other interventions or defining rehabilitation goals, and documenting patient care. The Core Sets for schizophrenia may also be used to promote interdisciplinary coordination and facilitate communication between members of a multidisciplinary rehabilitation team. Rehabilitation research is another potential area of application of the Core Sets for schizophrenia. This is valuable, since rehabilitation research provides crucial evidence for optimizing rehabilitation practice.

Self-Reported Graphic Personal and Social Performance Scale (SRG-PSP) for measuring functionality in patients with bipolar disorder

OBJECTIVES

The self-reported graphic version of the Personal and Social Performance Scale (SRG-PSP) is the first graphic, self-reported rating scale that assesses functioning, and its reliability and validity have been documented in patients with schizophrenia. This study investigated the validity of SRG-PSP in patients with bipolar disorder (BD).

METHODS

Patients with BD were recruited from psychiatric outpatient clinics, and assessed with the Young Mania Rating Scale (YMRS), the Montgomery-Åsberg Depression Rating Scale (MADRS), the Clinical Global Impression Scale (CGI)-Bipolar and CGI-Depression, the Positive and Negative Symptom Scale (PANSS), the Global assessment of function (GAF), and the PSP. All participants completed the self-rating questionnaires: the SRG-PSP, the 36-Item Short-Form Health Survey (SF-36), and the Sheehan disability Scale (SDS).

RESULTS

In total, 114 patients with BD were enrolled. The criterion-related validities between the SRG-PSP and the PSP were all significantly correlated with their counterparts. The global score of the SRG-PSP was significantly correlated with the scores of the YMRS, MADRS, PANSS, CGI-Depression, GAF, SF-36, and SDS. Three SRG-PSP domains (socially useful activities, personal and social relationships, and self-care) were negatively correlated with the scores of the MADRS, PANSS, CGI-depression, and SDS; and were positively correlated with the GAF, SF-36 scores. The disturbing and aggressive behavior domain was positively correlated with the scores of the YMRS, MADRS, PANSS, CGI-Bipolar, CGI-Depression, and SDS; and was negatively correlated with the GAF, SF-36 scores (all p<0.01).

CONCLUSION

The SRG-PSP is a validated self-reported scale for assessing functionality in patients with BD.

Identification of problems in the functioning of individuals with schizophrenia from the expert perspective: an Internet-based survey

PURPOSE

The purpose of the study was to identify aspects of functioning and related environmental factors that are relevant to schizophrenia from the perspective of health professionals experienced in treating individuals with this disorder using the International Classification of Functioning, Disability and Health (ICF).

METHOD

An international pool of experts from diverse health care disciplines was surveyed to identify problems in functioning experienced by individuals with schizophrenia and the environmental factors that impact their functioning. On the basis of established rules, all answers were translated to the ICF by two independent researchers.

RESULTS

One-hundred and eighty-nine experts from all six World Health Organization regions identified 4776 meaningful concepts, of which 92% were linked to 347 different ICF categories. Of the 347 categories, 194 were second-level categories, 151 were third-level categories and 2 were fourth-level categories. Ninety-five second-level ICF categories, 43 third-level categories and 1 fourth-level category reached percentage frequency of at least 5%. The majority of the categories were attributed to body functions, activities and participation, and environmental factors.

CONCLUSIONS

Health professionals identified a wide range of problems in functioning that reflect the complexity and breadth of schizophrenia, specifically activity limitations and participation restrictions that are particularly relevant for individuals with schizophrenia. Knowing these functioning problems can guide the design of patient-oriented rehabilitation programmes. Implications for rehabilitation Schizophrenia may result in impaired functioning in multiple daily life activities. The International Classification of Functioning, Disability and Health (ICF) can help in identifying the needs and problems of these individuals. The reported list of ICF categories can facilitate a systematic application of the ICF in schizophrenia and can help to design and implement coordinated and patient oriented rehabilitation programmes with a biopsychosocial approach. According to health professionals surveyed, activity limitations and participation restrictions are broadly affected in this population and are highly influenced by neurocognitive and social cognitive deficits and environmental factors.

A comprehensive scoping review of ability and disability in ADHD using the International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY)

This is the first in a series of four empirical investigations to develop International Classification of Functioning, Disability and Health (ICF) Core Sets for Attention Deficit Hyperactivity Disorder (ADHD). The objective here was to use a comprehensive scoping review approach to identify the concepts of functional ability and disability used in the scientific ADHD literature and link these to the nomenclature of the ICF-CY. Systematic searches were conducted using Medline/PubMed, PsycINFO, ERIC and Cinahl, to extract the relevant concepts of functional ability and disability from the identified outcome studies of ADHD. These concepts were then linked to ICF-CY by two independent researchers using a standardized linking procedure. Data from identified studies were analysed until saturation of ICF-CY categories was reached. Eighty studies were included in the final analysis. Concepts contained in these studies were linked to 128 ICF-CY categories. Of these categories, 68 were considered to be particularly relevant to ADHD (i.e., identified in at least 5 % of the studies). Of these, 32 were related to Activities and participation, 31 were related to Body functions, and five were related to environmental factors. The five most frequently identified categories were school education (53 %), energy and drive functions (50 %), psychomotor functions (50 %), attention functions (49 %), and emotional functions (45 %). The broad variety of ICF-CY categories identified in this study underlines the necessity to consider ability and disability in ADHD across all dimensions of life, for which the ICF-CY provides a valuable and universally applicable framework. These results, in combination with three additional preparatory studies (expert survey, focus groups, clinical study), will provide a scientific basis to define the ICF Core Sets for ADHD for multi-purpose use in basic and applied research, and every day clinical practice.

Quality of life as patient-reported outcomes: principles of assessment

Assessing quality of life (QoL) as a patient-reported outcome in adult psychiatry poses challenges in terms of concepts, methods, and applications in research and practice. This review will outline conceptually the construct of QoL, its dimensionality, and its representation across patient groups. Methodological challenges are examined, along with principles of QoL instrument development and testing, as well as across cultures. Application of instruments in epidemiological, clinical health economics, and health services research is reviewed based on pertinent literature. Validated measures for depression, psychosis, and anxiety disorders are available in adult psychiatry, and are increasingly used in research. Still, targeted measures are lacking for many mental health conditions and only rarely are tools applied in the practice context. Progress has been made in the development of instruments that are now ready for implementation. The information to be gained is valuable for identifying patient-reported needs for and benefits of treatment.

Disability in bipolar I disorder: the 36-item World Health Organization Disability Assessment Schedule 2.0

BACKGROUND

The WHODAS 2.0 is an ICF-based multidimensional instrument developed for measuring disability. The present study analyzes the utility of the 36-item interviewer-administered version in a sample of patients with bipolar disorder. There is no study to date that analyses how the scale works in a sample that only comprises such patients.

METHODS

A total of 291 patients with bipolar disorder (42.6% males) according to DSM-IV-TR criteria from a cross-sectional study conducted in outpatient psychiatric clinics were enrolled. In addition to the WHODAS 2.0, patients completed a comprehensive assessment battery including measures on psychopathology, functionality and quality of life. Analyses were centered on providing evidence on the validity and utility of the Spanish version of the WHODAS 2.0 in bipolar patients.

RESULTS

Participation domain had the highest percentage of missing data (2.7%). Confirmatory factorial analysis was used to test three models formulated in the literature: six primary correlated factors, six primary factors with a single second-order factor, and six primary factors with two second-order factors. The three models were plausible, although the one formed by six correlated factors produced the best fit. Cronbach's alpha values ranged between .73 for the Self-care domain and .92 for Life activities, and the internal consistency of the total score was .96. Relationships between the WHODAS 2.0 and measures of psychopathology, functionality and quality of life were in the expected direction, and the scale was found to be able to differentiate among patients with different intensity of clinical symptoms and work situation.

LIMITATIONS

The percentage of euthymic patients was considerable. However, the assessment of euthymic patients is less influenced by mood. Some psychometric properties have not been studied, such as score stability and sensitivity to change.

CONCLUSIONS

The Spanish version of the 36-item WHODAS 2.0 has suitable psychometric properties in terms of reliability and validity when applied to patients with bipolar disorder. Disability in bipolar patients is especially prominent in Cognition, Getting along, Life activities, and Participation domains, so functional remediation interventions should emphasize these areas in order to improve the daily living activities of these patients.

The association between diagnosis, treatment delay and outcome among patients with Bipolar disorders

Prevalence rates for Bipolar (BP) disorder are difficult for exact evaluation since the high rates of misdiagnosis and the delay from the initial symptoms until the treatment with mood stabilizers. This study aimed to find whether there was such a delay in a sample of Israeli outpatients diagnosed with BP. The study also aimed to assess outcomes associated with a delay in treatment. The sample included 56 ambulatory patients. Data were evaluated by a demographical questionnaire, according the medical records and by the Outcome dysfunctions scale, addressing four areas: work, symptoms, social contacts and duration of hospitalizations. The results revealed a time lapse of 2.2 years from the onset of BP to the initiation of treatment and a time lapse of 6.7 years between the onset and initiation of mood stabilizers. The delay in treatment was not correlated with any functional outcome, or suicidal behavior. In addition, the younger the subject was at the onset, the longer it took to initiate treatment with mood stabilizers. This research found a significant delay in treatment of patients with BP disorder. This delay was not associated with the expected functional impairment. We assume that personal resources had moderated this effect. This research may suggest that in Israel the referral of children to psychiatric services is especially delayed, possibly because of the potential damage to the military service enrollment. This research highlights the need to improve clinicians' recognition of BP in general, and among patients with early onset in particular.