Impact of living with bipolar patients: Making sense of caregivers’ burden

Mapping global evidence of caregiver experiences in bipolar disorder in low and middle-income countries: A scoping review

BACKGROUND

Bipolar disorder (BD) imposes significant social, psychological, and economic burdens on individuals and their caregivers. While developing treatments for BD patients is crucial, supportive interventions for caregivers in low- and middle-income countries (LMICs) are equally important, given the limited resources and healthcare infrastructure. Understanding caregiver experiences in these settings is essential for creating effective interventions. This scoping review synthesizes knowledge of caregiver experiences in assisting individuals with BD in LMICs.

METHODS

Following Arksey and O'Malley's scoping review framework, we examined quantitative and qualitative studies on caregiver experiences. A comprehensive literature search was conducted across five databases, with two authors independently screening studies, extracting data, and reviewing references for additional eligible studies. Findings are presented through narrative synthesis according to PRISMA-ScR guidelines.

RESULTS

Out of 3518 records, 104 studies met the eligibility criteria. Five main themes and eight subthemes were identified: (1) burden of caregiving (impaired quality of life), (2) caregiver challenges (lack of understanding, family/social disruptions, financial restraints, mental and physical fatigue), (3) caregiver needs (information access, involvement, social support, financial assistance), (4) coping mechanisms, and (5) the silver lining in caregiving.

CONCLUSIONS

This review highlights significant challenges faced by caregivers of individuals with BD in LMICs, emphasizing the need for better psychoeducation, healthcare communication, and supportive resources. Addressing financial constraints and stigma is also crucial. Future research should focus on culturally adapting evidence-based strategies to support caregivers in these settings.

The Impact of Patient-Centered Care in Bipolar Disorder: An Opinion on Caregivers' Quality of Life

Background/Objectives: Our background comprises the previously identified consequences of bipolar disorder's chronicity, which significantly affects not only the patients but also their caregivers, leading to challenges in caregivers' physical, emotional, and financial well-being. This impact on caregivers' quality of life (QOL) is often overlooked in the context of patient-centered care for bipolar disorder. Our objective was to explore how patient-centered care in bipolar disorder management affects caregivers, with a focus on improving both patient and caregiver outcomes. Methods: We performed a thematic qualitative synthesis of reviewed literature and case studies to explore the intersection of patient-centered care in bipolar disorder management and its impact on caregivers. This comprehensive review allowed us to identify key behavioral patterns and emotional fluctuations in patients that significantly affect caregiver well-being, with a focus on the challenges caregivers face due to the unpredictability of mood episodes and the lack of adequate support in current care models. Results: In the results, we identified that while patient-centered care enhances patient outcomes, it also exacerbates the strain on caregivers if their needs are not adequately addressed. Specific behavioral pathways and emotional fluctuations in bipolar disorder impact caregivers, such as the unpredictability of mood episodes, cognitive distortions during manic and depressive phases, and the emotional toll of managing crises. This article also emphasizes the role of patient-centered care, which places the patient at the core of treatment decisions, but often neglects the strain placed on caregivers. Conclusions: We conclude that a holistic approach to care, which includes caregiver support and resources, is essential for improving the QOL of both patients and caregivers. Future research is needed to develop strategies and interventions that better support caregivers and enhance their overall well-being, ensuring that patient care models are truly comprehensive.

Adaptive Hyperactivity and Biomarker Exploration: Insights from Elders in the Blue Zone of Sardinia

Background/Objectives: Adaptive hyperactivity characterized by increased activity levels and novelty-seeking traits without mood disorders is prevalent among older adults in Sardinia's "blue zone," an area with high longevity. This study aims to evaluate the adaptive nature of hyperactivity concerning quality of life, social rhythms, and mood symptoms in individuals from this region, particularly among elderly adults over 80. Methods: This observational cross-sectional study included adults and older adults over 80 from Sardinia's blue zone. This study included a sample of patients followed at the Center for Consultation Psychiatry and Psychosomatics for Bipolar Disorder of the University Hospital of Cagliari and a homogeneous comparison sample of patients without psychiatric pathologies, referred to the Dermatology Clinic of the same hospital, for a period of 6 months, from February to August 2024. The general sample, divided into two parts-cases, represented by patients with psychiatric pathology, and controls, patients without psychiatric pathology-was divided in turn into three sub-groups: "adults" (18-64 years), young elders (65-79), and old elders (over 80 years). The participants underwent psychiatric interviews and completed the Mood Disorder Questionnaire (MDQ), Patient Health Questionnaire (PHQ-9), SF-12, and Brief Social Rhythm Scale (BSRS). Data were compared with national and regional normative data. Results: Older adults in the blue zone demonstrated higher MDQ positivity (22.58%) compared to the national averages (0.87%), without corresponding increases in dysregulated rhythms, depressive symptoms, or reduced quality of life. Younger old persons (65-79 years) showed increased rhythm dysregulation (BSRS score: 20.64 ± 7.02) compared to adults (17.40 ± 6.09, p = 0.040), but this trend was not observed in the oldest group (80+ years). No significant differences were found in the CH3SH and (CH3)2S levels between groups. Conclusions: The hyperactivity observed in older adults from Sardinia's blue zone appears adaptive and not linked to social rhythm dysregulation, depressive symptoms, or a diminished quality of life, suggesting resilience factors which may contribute to longevity. These findings support the potential classification of such hyperactivity as beneficial rather than pathological, warranting further research into biomarkers and psychoeducational interventions to prevent the onset of bipolar disorders in predisposed individuals.

Lived experiences of adults' non-compliance with psychiatric medication for depression

Background

Non-compliance with psychiatric medication among patients diagnosed with depression ranges from 28% to 52% exacerbating illness and reducing treatment effectiveness. There is a paucity of research on medication non-compliance and its causes in South Africa and globally, and an urgent need to develop appropriate interventions.

Aim

This study aimed to explore and describe the experiences of adults living with depression who are non-compliant with their psychiatric medication and formulate recommendations to facilitate their medication compliance.

Setting

The study was conducted in a psychiatric ward at a public hospital in Gauteng, South Africa.

Methods

The study employed a qualitative, exploratory, descriptive and contextual research design. Ten adults' lived experiences were explored using in-depth individual interviews, and Tech's coding method was used to analyse data.

Results

Two themes emerged from the data: adults living with major depression offered several reasons for non-compliance, and adults living with major depression experienced non-compliance, which created a setback to their recovery.

Conclusion

Non-compliance with medication is a common challenge among adults receiving mental health care and treatment. Ensuring compliance to medication is crucial for improving the prognosis of psychiatric conditions. Therefore, it is essential for healthcare practitioners in the field of psychiatry to have a comprehensive understanding of medication compliance and to effectively address any challenges that may arise in this area.

Contribution

This paper contributes to the research field and adds knowledge to clinical nursing practice by exploring adults' experiences with non-compliance to psychiatric medications while living with depression in the South African context.

Is it possible to predict hospitalisation during intensive home treatment? A retrospective cohort study

OBJECTIVE

Intensive Home Treatment (IHT) is an alternative to acute inward treatment. The objective of this study was to assess which variables predict that a patient admitted to IHT required transfer to hospital for inward management.

METHODS

We included the first 1000 episodes admitted to IHT and looked for crude associations between potential predictive factors and transfer to hospital. Then, we built a predictive model for this outcome.

RESULTS

The patients with a higher risk of transfer to hospital were those who had previous hospitalisations (OR = 2.6; 95% CI = 1.4-4.7), more admissions in the previous 5 years (median= 0, IQR = 0-1 vs. median = 0, IQR = 0-1.5; p = 0.0011) and a higher clinical severity at IHT admission (mean difference = 0.36; p50 = 0, IQR = 0-1.5 vs. p50 = 0, IQR = 0-1; p = 0.0011). The predictive model included age, previous admissions, clinical severity at IHT admission, and substance use at the beginning of the episode but had a low performance (R2 = 0.115; AUC = 0.752, 95% CI: 0.690-0.814).

CONCLUSION

Our results are consistent with those from previous studies in countries with different mental health systems. Far from cautioning us against using IHT in patients with severe symptoms or previous hospitalisations, these results should encourage us to find ways to offer them greater support at home.

The research landscape of bipolar disorder in Germany: productive, but underfunded

BACKGROUND

The recurrent mental illness bipolar disorder is a major burden on the healthcare system, which underlines the importance of research into this disease. Germany is one of the most productive countries in this research activity. This bibliometric analysis aims to outline the social and conceptual structure of the German research landscape on bipolar disorder over the last decade. Furthermore, we provide a short overview over current public funding.

RESULTS

Concerning the social structure, most of the German publications were collaboration projects, both with a national but also international orientation, in the latter case predominantly with countries of the global North. Analysis of the conceptual structure of German research activity identified psychiatric genetics, early recognition of bipolar disorder, neuroimaging, and pharmacological interventions as important topics within the field. In the context of a survey, only few publicly funded research projects were reported, many of which did not exclusively investigate bipolar disorder but followed a transdiagnostic approach.

CONCLUSIONS

Our bibliometric analysis revealed internationally well-networked German research activities on bipolar disorder. In stark contrast to its high prevalence and correspondingly high financial burden to the healthcare system, current grant support for research on this illness is strikingly low, particularly concerning the development of novel treatments.

The prevalence and associated characteristics of Bipolar Disorder diagnosis among admitted patients at three tertiary psychiatric hospitals in Zimbabwe: A cross sectional study

BACKGROUND

Bipolar Affective Disorder (BD) is a serious condition that affects more than 1% of the world's population. If not treated can cause disability, yet its prevalence in Zimbabwe is not known. This study explores the burden of Bipolar Disorder and its associated factors in Zimbabwe.

METHODS

A cross sectional study with a sample of 272 participants was carried out at three tertiary hospitals in Zimbabwe. Data was collected using an interviewer administered questionnaire and the Mini International Neuropsychiatric Interview (M.I.N.I). The study shows the prevalence and factors associated with Bipolar Disorder at tertiary psychiatric hospitals. Data analysis was done using STATA S/E 13.0 for data management.

RESULTS

The prevalence of BD in the sample was 39.3%. Factors associated with BD were, being formally employed (AOR = 3.69, 95%CI: 1.55-8.79), a history of defaulting medications (AOR = 1.90, 95%CI: 1.02-3.57) and a reported previous diagnosis of BD (AOR = 5.66, 95%CI: 2.72-11.8).

CONCLUSIONS

The prevalence of BD among admitted participants in tertiary psychiatric hospitals in Zimbabwe is high. It is comparable to that from African studies done in clinical settings. There is need for in-service training for clinicians to be more vigilant in diagnosing BD.

Proches aidants en psychiatrie : quelle (in)adéquation entre besoins et offres de soutien ?

INTRODUCTION

Informal caregivers play a vital role in supporting people with severe mental illness. However, this role can leave informal caregivers with significant unmet needs. The aim of this qualitative study is to identify the extent to which the support offered to informal caregivers in adult psychiatry in French-speaking Switzerland meets their needs.

METHOD

Individual semi-structured interviews and focus groups were conducted with informal caregivers, mental health professionals, and service providers. The data were analyzed by theme.

RESULTS

The need for assistance and the need for information are two themes identified as prevalent among informal caregivers. Despite a consensus on the need for more support and information, informal caregivers, service providers, and health professionals do not assign the same importance to specific aspects of these themes. Suggestions for improving practices at the institutional, socio-political, and civil-society levels are put forward. Given the diversity of viewpoints on the priority needs of informal caregivers, there is a risk of offering support that only partially corresponds to the difficulties encountered by informal caregivers.

CONCLUSIONS

Matching support and needs remains a major challenge. Agreeing on a consensual definition of support and information needs and proposing tailored approaches could make it possible to develop support services that meet the actual needs of informal caregivers.

Caregivers' Burden in Patients With Bipolar Disorder and Schizophrenia and Its Relationship With Anxiety and Depression in Caregivers: A Narrative Review

Mental disorders affect a person's thinking, mood, and/or behaviour and can range in severity from minor to severe. Nearly one in five persons have a mental disease as stated by the National Institute of Mental Health. A serious mental illness called bipolar disorder causes extreme mood swings that can range from manic to depressive states. Schizophrenia is a brain condition that leads individuals to perceive reality differently. They cannot distinguish between what they are actually experiencing and what they are just imagining. Both illnesses have a variety of negative effects on the patient as well as the primary caregiver, who may be the patient's family or other relatives. In the case of a patient with mental illness, the family's role is crucial. Family members' long-term caregiving obligations may result in a caregiving burden that negatively impacts the caregivers' quality of life, career and personal relationships. Depression generally undermines carers' ability to fulfil their crucial supportive role towards their relative with a mental illness while contributing to their distress and handicap. Given the high prevalence of caregiver depression, it is critical to address this issue not just by creating therapies to treat caregiver depression once it has started, but also by preventing caregiver depression.

The bipolar patients' family experiences of the outcomes of encountering stigma in Tehran: A qualitative study

INTRODUCTION

Nowadays, the most common psychological-social pressure to which bipolar patients' families are exposed is stigma. Therefore, the present study was conducted to delve into the bipolar patients' family experiences of the outcomes of encountering stigma.

METHOD

The study was of qualitative type. Purposive sampling was used to select the participants from the persons suffering from bipolar disorder and their families. Twenty seven of the participants were interviewed. The main data collection instrument was semi-structured interview with open questions. Additionally, the collected data were analyzed via inductive content analysis method. The accuracy and validity of the study rooted in four factors: credibility, transferability, verifiability, and reliability.

RESULTS

Data analysis led to 1,326 primary codes, which were further categorized into five main categories as the main outcomes of encountering stigma (social deprivation, emotional and sentimental excitement, objective and behavioral reflections, family solidarity threat, and separation from society) and 21 sub-categories.

CONCLUSION

Given then irreparable outcomes of stigma for bipolar patients' family, it is necessary to take it into consideration. It is recommended to use media and also hygienic-treatment centers to educate different levels of society as to appropriate treatment with these patients and their families.

The Relationship among Dyadic Adjustment and Disease Burden in Patients with Bipolar Disorder and Their Spouses

(1) Background: Spouses of individuals with bipolar disorder (BD) experience significant burdens, and the perception of the burden may affect dyadic adjustment. We aimed to investigate the sexual functions, alexithymic traits, marital satisfaction, and burden in patients with BD and their spouses. We also aimed to assess the mediating role of sexual functions and alexithymia in the relationship between burden and dyadic adjustment. (2) Methods: We included 81 patients with BD type 1 (40.69 ± 8.55 years, 65.4% female, and 34.6% male) and their healthy spouses (40.95 ± 7.30 years, 34.6% female, and 65.4% male) and 78 healthy controls (38.90 ± 5.88, 48.7% female, and 51.3% male). The participants were evaluated using the Golombok-Rust Inventory of Sexual Satisfaction (GRISS), Dyadic Adjustment Scale (DAS), Hamilton Depression Rating Scale (HDRS), Toronto Alexithymia Scale-20 (TAS-20), and Burden Assessment Scale (BAS). (3) Results: The GRISS scores of the control group were significantly lower than the spouses and BD groups. The DAS total score of the control group was significantly higher than that of the spouses and BD groups. Regression analyses revealed that TAS, GRISS, and HDRS scores were associated with DAS scores in the BD group. In the spouse group, TAS and BAS scores were associated with DAS scores. The GRISS scores partially mediated the relationship between dyadic adjustment and burden in the spouses of patients with BD. (4) Conclusions: Mental health professionals should regularly scan caregivers' perceptions of burden. Appropriate psychosocial interventions could help spouses of patients with BD to cope better with the burden and improve dyadic adjustment.

How Do Shifts in Patients with Mental Health Problems' Formal and Informal Care Utilization Affect Informal Caregivers?: A COVID-19 Case Study

(1) Background: This study investigated how potential shifts in patients' formal and informal care utilization during the COVID-19 pandemic impacted their informal caregivers in terms of their subjective burden, psychological wellbeing, and happiness. (2) Methods: A retrospective cohort study design was employed for a panel of Dutch informal caregivers of persons with mental health problems (n = 219) in June 2020. Descriptive statistics and differences between means were determined for the patients' informal and care utilization and informal caregivers' subjective burden, happiness, and psychological wellbeing. Three mediation analyses were conducted using the PROCESS macro. (3) Results: Informal caregivers reported significantly worse happiness and subjective burden scores during the COVID-19 pandemic compared with before the lockdown. There were minimal shifts in patient's care utilization reported, with the exception of a decrease in significant emotional and practical support provided by the informal caregiver. In the mediation analyses, there was not a significant indirect effect of shifts in patients' formal care utilization on informal caregivers' subjective burden, psychological wellbeing, and happiness through shifts in patients' informal care utilization. (4) Discussion and conclusion: Whilst we found that shifts in patients' care utilization during the first wave of the pandemic did not affect the informal caregiver in the short term, it is unclear what the long-term impact of the pandemic might be on informal caregivers. More research should be conducted to understand the implications of short- and long-term impact of substitution on informal caregivers of persons with mental health problems, with special consideration of the COVID-19 context and uptake of e-health technology.

A Different rTMS Protocol for a Different Type of Depression: 20.000 rTMS Pulses for the Treatment of Bipolar Depression Type II

In this open-label naturalistic study, we assess the feasibility, tolerability, and effectiveness of a repetitive transcranial magnetic stimulation protocol with a reduced total pulse number for treating patients suffering from bipolar disorder type II. All patients received one rTMS treatment session of 1000 pulses for 20 consecutive working days, accumulating to 20.000 rTMS pulses applied over 4 weeks. We measured the patients’ symptoms before the start, halfway through, directly after, and one month after treatment. We quantified the depression symptoms using both the Beck depression inventory scale and the symptom checklist-90 depression subscale. Patients showed a significant reduction in depression symptoms directly after treatment and an even further reduction one month after treatment. The remission rates were at 26% halfway through treatment (after the 10th session), 61% directly after treatment (after the 20th session), and increased to 78% at the 1-month follow-up. Importantly, the protocol proved to be feasible and highly tolerable in this patient population, with no adverse effects being reported. Considering these positive results, further research should focus on replicating these findings in larger clinical samples with control groups and longer follow-up periods, while potentially adding maintenance sessions to optimize the treatment effect and stability for bipolar disorder type II patients.

COVID-19 lockdown - who cares? The first lockdown from the perspective of relatives of people with severe mental illness

BACKGROUND

Informal care is vital to many people with severe mental illness under normal circumstances. Little is known about how extraordinary circumstances affect relatives with a family member with mental illness. This study investigated the consequences of the first COVID-19 lockdown in Norway from the perspective of relatives of persons with psychotic- and/or bipolar disorders: What were the challenges and for whom?

METHOD

Relatives were invited to complete an online survey shortly after the first lockdown was initiated. Both quantitative and qualitative data were collected concerning experiences of relatives' own and their affected family members' health and situation. Two hundred and seventy-nine relatives completed the survey, mostly mothers and partners.

RESULTS

One-third of the relatives reported considerable deterioration in their family members' mental health, and a substantial minority worried about severe self-harm or suicide. Main themes in the qualitative analyses were "Isolation and its effects on mental health", "Worrying about the pandemic and its consequences", "Increased symptomatology" and "Suicide". Being a relative during the lockdown put heavy strain on the relatives' own health, in particular disturbance of sleep, concentration, and the ability to take care of others in the family. Relatives of family members with psychotic bipolar disorder, not currently in treatment, or living with their family experienced the situation especially challenging.

CONCLUSIONS

Many relatives found the first lockdown hard for their family. Efforts to integrate relatives' perspectives in health care and contingency plans under normal circumstances could potentially alleviate some of the extra burden experienced by families during extraordinary circumstances.

Improving the Assessment Process of Family Functioning in Adult Bipolar Disorders: A PRISMA Systematic Review

In order to determine family functioning in the treatment of adults with bipolar disorders, guidelines are needed regarding the way family functioning may be assessed. The present systematic review aims to investigate how family functioning is assessed in this context. Following PRISMA guidelines, a total of 29 studies were reviewed. Results showed that although there was no consensual family functioning assessment across studies, 27 studies (93%) relied on self-report questionnaires, 12 studies (41%) relied on one family member as an informant (adult with bipolar disorder or other) and the adult considered was mostly a woman in the acute phase of bipolar I disorder. Significant heterogeneity was observed in the assessment of family functioning. Methodological considerations regarding the assessment of family functioning are discussed.

Social support in patients with bipolar disorder and differing ages at onset

OBJECTIVE

The main purpose of this study was to evaluate the association between age at onset and social support in outpatients with bipolar disorder who were in the recovery phase. We also investigated the association between age at onset and disability.

METHODS

A total of 180 bipolar disorder I outpatients, of whom 50 had early onset with age at onset ≤18 years old, 108 had middle onset with age at onset between 19 and 39 years old, and 22 had late onset with age at onset ≥40 years old, were assessed with the Medical Outcomes Study Social Support Scale and Sheehan Disability Scale.

RESULTS

The early onset group had lower tangible social support, longer length of illness, more childless participants, lower income and more suicide attempters than the late onset group.

CONCLUSIONS

Early onset seems to have inferior outcomes in tangible social support than late onset, but this trend should be considered as a starting point for future studies.

Perceived stress, marital satisfaction, and sexual satisfaction in spouses of males having bipolar disorder with and without alcohol use disorder: A cross-sectional study

BACKGROUND

Bipolar affective disorder (BPAD) and alcohol use disorder (AUD) are frequently comorbid and affect the social, occupational, and personal domains of patients and their spouses.

AIM

This cross-sectional study was conducted to assess and compare the levels of stress, marital satisfaction, and sexual satisfaction between the spouses of males with BPAD + AUD and of those without AUD.

MATERIALS AND METHODS

Spouses of 100 males with diagnosed BPAD, currently in remission, including fifty patients having comorbid AUD, were recruited as participants. Participants were assessed with Perceived Stress Scale-10, Dyadic Adjustment Scale, and Sexuality Scale.

STATISTICAL ANALYSIS

Descriptive statistics, Chi-square, t-test, analysis of variance, and correlation on SPSS were used for statistical analysis.

RESULTS

More stress (59%), poorer marital (53%) and sexual satisfaction (89%) were found in the majority participants, with significantly higher stress in the group with husbands having both BPAD + AUD (P < 0.01). Duration of cohabitation had a direct, and education and family income had inverse relations with stress.

CONCLUSIONS

BPAD worsens stress, marital satisfaction, and sexual satisfaction in the study participants, the stress increasing further with comorbid AUD. Education, family income, and duration of cohabitation have a significant bearing on stress.

Why doesn't God say "enough"? Experiences of living with bipolar disorder in rural Ethiopia

RATIONALE

Little is known about the specific experience people living with bipolar disorder in rural, low resource settings, where conditions that disrupt normal social interactions are often highly stigmatized and evidence-based treatments are rare.

OBJECTIVE

To explore illness experience, coping strategies, help-seeking practices, and consequences of illness among people with bipolar disorder (PBD) and their family members in rural Ethiopia as an initial step for developing psychosocial intervention grounded by the experiences of PBD.

METHOD

A qualitative methods using in-depth interviews were carried out with 27 individuals (15 PBD and 12 caregivers). The participants were identified on the basis of previous community-based research among people with severe mental illness. Interviews were carried out in Amharic, audio-recorded, transcribed, and translated into English. Data were analyzed using thematic analysis. Our approach was informed by phenomenological theory.

RESULT

Three major themes emerged: expressions and experiences of illness, managing self and living with otherness, and the costs of affliction. PBD and caregivers were concerned by different forewarnings of illness. Stigma and social exclusion were entwined in a vicious cycle that shaped both illness experience and the economic health and social life of the household. Nonetheless, PBD and caregivers learned from their experiences, developed coping strategies, and sought relief from trusted relationships, spirituality, and medication.

CONCLUSION

Our findings suggest that psychosocial intervention could be used to strengthen existing resources, in order to improve the lives of PBD and their family members. However, pervasive stigma may be a barrier to group and peer support approaches.

A Systematic Review and Meta-Analysis of Randomized Sham-Controlled Trials of Repetitive Transcranial Magnetic Stimulation for Bipolar Disorder

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) is effective in treating unipolar depression. However, the efficacy of rTMS in bipolar disorder (BD) is unclear. This meta-analysis aimed to examine the efficacy and tolerability of rTMS for both depressive and manic phases in BD.

METHODS

MEDLINE, EMBASE, PsycINFO, CENTRAL databases were searched for controlled trials on treatment of BD with rTMS. Primary outcomes included changes in depression or mania scores, response and remission rates. Secondary outcomes included quality of life and functioning assessment. We used random-effects model, Hedge's g, risk differences (RDs) and the number needed to treat (NNT).

RESULTS

Eleven randomized sham-controlled studies were included, with a total of 345 patients with BD (bipolar depression = 257, mania = 86, mixed affective = 2). Trials of rTMS in bipolar depression (N = 8) demonstrated small but significant improvement in depression scores [standardized mean difference = 0.302, p < 0.05], compared to control group. Furthermore, rTMS brought a higher remission rate than sham-controls [RD = 0.104 ± 0.044, p < 0.05, NNT = 10; and a trend of greater response rate [RD = 0.074 ± 0.039, p = 0.06]. Results were inconclusive for effect of rTMS in mania. In both depressive and manic groups, no serious adverse events were reported. Risk of treatment-emergent mania appeared low.

LIMITATIONS

There was limited number of eligible primary studies, with variable randomization procedures.

CONCLUSION

rTMS appears safe and effective in treating bipolar depression. More stringent RCTs are necessary for concrete conclusion about efficacy in mania.

Burden in Tunisian Family Caregivers of Older Patients with Schizophrenia Spectrum and Bipolar Disorders; Associations with Depression, Anxiety, Stress, and Quality of Life

BACKGROUND

There are very little data on the burden among caregivers of older adults with severe mental diseases. We aimed to assess the perceived burden among caregivers of family members with schizophrenia spectrum and bipolar disorders.

METHOD

A cross-sectional study was carried out with 52 older patients with schizophrenia spectrum and bipolar disorders and their family caregivers. Caregivers were assessed with the medical outcome survey short form (SF-36), the Zarit Burden Interview (ZBI) and the Depression Anxiety and Stress scales (DASS-21).

RESULTS

Caregivers' mental quality of life was impaired with an average mental score of 59.05. For a threshold value of 17, the level of perceived burden was considered as high for 42.3% of caregivers. After controlling for demographic variables (age and gender) and patients' health-related variables (level of dependency, comorbidities, age onset of illness, number of hospitalizations and duration of clinical remission), caregivers' levels of depression, stress, and SF-36 physical component significantly contributed to their perceived burden.

CONCLUSIONS

Certain modifiable risk factors play an inescapable role in increasing the level of burden among caregivers of older patients with serious mental illnesses.

CLINICAL IMPLICATIONS

Improving the quality of life and psychological well-being of family caregivers should be considered an integral part of treatment for serious mental illness in older adult patients.

Psychometric properties of the Spanish version of the Experience of Caregiving Inventory (ECI) among caregivers of individuals with an eating disorder

PURPOSE

The aim of this study was to examine the psychometric properties of the Spanish version of the Experience of Caregiving Inventory (ECI-S), which is designed to assess the caregiver's appraisal of the impact of caring for a relative with a serious mental illness.

METHODS

A cross-sectional study was conducted among 320 caregivers of a relative with an eating disorder to examine: (a) descriptive statistics; (b) internal consistency reliability; (c) the fit of the original ten-factor structure of the ECI through exploratory factor analysis, using a semi-confirmatory approach, for each subscale individually, and (d) concurrent validity. A total of 307 caregivers completed the scale.

RESULTS

Reliability of the ECI subscales scores was acceptable (α = 0.63-0.89). Results replicated the original ten-factor structure of the instrument. The concurrent validity was supported by correlations of the ECI-negative subscale with psychological distress (GHQ-12, 0.43), and with depression and anxiety (HADS, 0.48 and 0.49, respectively).

CONCLUSIONS

The Spanish version of the ECI (ECI-S) demonstrated good psychometric properties in terms of validity and reliability that were similar to the original version. It is an acceptable and valid instrument for assessing the impact on family members of caring for a relative with an eating disorder and can be recommended for use in clinical settings in Spain.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

A systematic review of online interventions for families of patients with severe mental disorders

BACKGROUND

Several studies show the effectiveness of face-to-face interventions with families in improving the prognosis of patients with severe psychiatric disorders and their relatives; however, the effectiveness of online interventions is poorly understood. The current study aims to provide an overview of evidence for the effectiveness of online treatments (web/app) for patients with severe psychiatric disorders and their families.

METHOD

We performed a systematic review of online treatments for informal family caregivers of patients with a severe psychiatric disorder. The study psychological interventions had to have been administered in an exclusively online format (app, internet) and aimed at families of patients with severe mental disorder (at least one of first episode psychosis, schizophrenia, schizoaffective, bipolar disorder, and psychotic disorder).

RESULTS

Of a total of 1331 articles, we identified 9 viable studies; 4 randomized clinical trials, and 5 nonrandomized clinical studies. The present study is the first systematic review in this area. Online interventions were well accepted, with good adherence and satisfaction among the caregivers and patients and improved the symptoms of both caregivers and patients.

LIMITATIONS

Clinical and methodological diversity of the studies.

CONCLUSIONS

Burden improved, and perceived stress decreased in families. Moreover, the severity of positive symptoms decreased and fewer hospitalizations were recorded in patients than in the control group. Therefore, online interventions are a promising therapeutic approach for patients with severe mental disorder and their families. However, more studies-particularly randomized clinical trials-are needed in this area.

Affective temperaments in caregiver of patients with bipolar disorder and their relation to caregiver burden

BACKGROUND

Bipolar disorder (BD) is impose a severe burden on caregivers. The aspects of the burden should be evaluated from broad perspective, because caregivers contribute greatly to the treatment process. Affective temperaments are widely distributed in the population, in their mild forms can provide adaptive properties. The aim of this study was to assess the affective temperaments among caregiver of patients with BD and to evaluate the impact of affective temperaments on the burden.

METHODS

The study sample included 101 caregivers of patients diagnosed with BD type I according to DSM-5 and 107 healthy volunteers. The Temperament Evaluation of the Memphis, Pisa, Paris and San Diego self-report questionnaire (TEMPS-A), Hamilton Depression Rating Scale (HDRS), and Hamilton Anxiety Rating Scale (HARS) were administered to both groups, and the Burden Assessment Scale (BAS) was administered to caregivers.

RESULTS

The hyperthymic and depressive temperament scores were higher in the caregivers than in the controls, and hyperthymic and depressive temperaments were predictor factors for caregiver. Irritable temperament also adversely affected the caregiver burden, but hyperthymic temperament was not related to development of burden. The mean BAS score was 43.2 ± 11 for the caregivers. The caregiver HDRS and HARS scores and the number of manic episodes were related to the level of burden.

LIMITATION

Cross-sectional study CONCLUSION: Affective temperaments may be related to being a caregiver and to the caregiver burden. Hyperthymic and depressive temperaments may indicate predisposition for being a caregiver. Irritable temperament adversely affects burden, whereas hyperthymic temperament could protect the caregiver from burden.

Multidimensional impact of severe mental illness on family members: systematic review

OBJECTIVE

The impact of severe mental illnesses (SMIs) is not limited to the person with the illness but extends to their family members and the community where the patient comes from. In this review, we systematically analyse the available evidence of impacts of SMI on family members, including parents, grandparents, siblings, spouses and children.

DATA SOURCES

PubMed, PsycINFO, Embase and Global Index Medicus were searched from the inception of each database up to 9 November 2019. We also did manual searches of grey literature.

ELIGIBILITY CRITERIA

We included studies that assessed the impacts of SMI on any family member. We excluded studies in admitted clinics and acute wards to rule out the acute effect of hospitalisation.

DATA EXTRACTION

Two reviewers extracted data independently using the Cochrane handbook guideline for systematic reviews and agreed on the final inclusion of identified studies.

RISK OF BIAS

The quality of the included studies was assessed using effective public health practice project quality assessment tool for quantitative studies.The review protocol was registered in the PROSPERO database.

RESULTS

We screened a total of 12 107 duplicate free articles and included 39 articles in the review. The multidimensional impact of SMI included physical health problems (sleeplessness, headache and extreme tiredness.), psychological difficulties (depression and other psychological problems) and socioeconomic drift (less likely to marry and higher divorce rate and greater food insecurity). Impacts on children included higher mortality, poor school performance and nutritional problems. However, the quality of one in five studies was considered weak.

CONCLUSIONS

Our review indicated a high level of multidimensional impact across multiple generations. The serious nature of the impact calls for interventions to address the multidimensional and multigenerational impact of SMI, particularly in low/middle-income countries. Given the relatively high number of studies rated methodologically weak, more robust studies are indicated.

PROSPERO REGISTRATION NUMBER

CRD42018064123.

Comparative Analysis of Spouse’s Burden and Quality of Life in Major Depressive Disorder and Bipolar I Disorder

Background:

Spouses of patients with bipolar disorder may experience a different quality of life and burden than seen with major depressive disorder.

Objective:

This study was conducted to comparatively analyse spouse’s burden and quality of life in major depressive and bipolar disorders.

Methods:

This cross-sectional study was conducted on 220 spouses of patients with major depressive and bipolar disorders in the city of Hamadan in Iran, in 2018. Data collection tools included Zarit Burden and QOL-BREF questionnaires. Data were analyzed by a t-test using SPSS -16.

Results:

The findings showed that 11.8% of spouses of patients with depression and 85.5% of spouses of patients with bipolar disorder experienced severe burden (P < 0.001). The quality of life of spouses of patients with bipolar disorder was lower than with depressive disorder (P < 0.05). In both the groups, a negative correlation was found between burden and QOL.

Conclusion:

The spouses of patients with bipolar disorder experience more burden and lower quality of life than depression. In both the groups, burden has a negative impact on the quality of life. Professional help and supportive intervention can be provided to the spouses of patients with major depressive and bipolar I disorders to reduce their burden, strengthen their coping skill and thus improve their QOL.

Marital Problems among Partners of Patients with Bipolar Affective Disorder

BACKGROUND

Partners of patients with bipolar affective disorder (BPAD) have problems with their marital life. Identification of these problems is important to develop strategies to solve them for improving quality of life.

AIMS

To identify marital distress and problem areas in their marital life among the partners of patients with BPAD.

MATERIALS AND METHODS

A cross-sectional descriptive design was used to collect data from 125 participants, 59 males and 66 females, who were partners of patients with BPAD. The study was done in outpatient clinics of Community Mental Health Clinics of District Mental Health Program. Tools used for data collection included a semi-structured interview schedule to collect socio-personal data of partners of patients with BPAD and clinical data of the patient, Couple Satisfaction Index (CSI), and Problem Areas Questionnaire (PAQ). Purposive sampling technique was used.

RESULTS

Majority of the participants (male - 55.9%, female -54.5%) expressed marital distress on CSI. Handling family finances and career/job decisions were the most problematic areas for male participants, whereas household tasks, handling finances, and career/job decisions were the most problematic areas for female participants.

CONCLUSION

A significant proportion of spouses of BPAD patients have marital distress in important areas of life, with a potential for long-term consequences in their lives.

Understanding the role of m-health to improve well-being in spouses of patients with bipolar disorder

OBJECTIVES

Spouses and partners of individuals with bipolar disorder (BD) experience significant burden. As there are some limitations to standard psychosocial caregiver interventions, mobile health technology (mHealth) may be a way to reduce burden and improve well-being in these caregivers. The purpose of this study was to explore how the well-being of spouses or partners of patients with BD can be improved through mHealth technology.

METHODS

Using a qualitative design, we conducted five focus groups and one in-depth individual interview to collect information from participants about what they would expect from such a device. The sample consists of thirteen participants (eleven spouses and two partners). The age range was 29-65, with eight females and five males. Data were collected using minimally structured interviews and independently analyzed by the authors using content analysis.

RESULTS

Results indicated that the mHealth device many be helpful in at least six areas: reduction of stressors, decreased social isolation, improving communication in the relationship between the spouses, speaking with children about the illness, managing medications, and providing information on resources.

CONCLUSION

Mobile health technology may be a feasible, available, and cost-effective support tool for spouses and partners of individuals with BD, especially in reducing caregiver stress. Future research is needed to develop the application and test its effectiveness on health outcomes in a larger trial.

An asymmetric burden: Experiences of men and women as caregivers of people with psycho-social disabilities in rural North India

Caring for a family member with a psycho-social disability can be both rewarding and burdensome. This study analyses the experiences of caregivers of people with psychosocial disabilities (PPSDs) in rural communities in North India using relational gender theory. In-depth interviews with 18 female and male caregivers of PPSDs probed the social, emotional and health impacts of their caregiving role. Nine themes were identified that were grouped under three meta-themes: intra-personal, inter-personal and institutional impacts. Under the intra-personal meta-theme, all caregivers experienced high tension, with women describing almost overwhelming stress. Women minimised their role as caregivers, and felt negative and hopeless about their futures, while men had a more positive view of the future and themselves. Embodied experiences of psychological and social distress were consistently described by women, but not by men. Within the interpersonal meta-theme, men experienced opportunity for social connection and social support that was seldom available to women. Interpersonal violence with other household members was described by both men and women. Within the institutional meta-theme, both men and women described strength in unity, and gestures leading to the reordering of gender relations. These findings underline the significant and diffuse impacts of a gender order that values males and disadvantages females as caregivers of PPSDs, with the asymmetry of a greater burden for women. The findings point to the urgent need for global mental health policies that support and empower caregivers and that strengthen gender equality.

Public Awareness, Beliefs, And Attitudes Toward Bipolar Disorder In Saudi Arabia

OBJECTIVES

To examine public's knowledge, beliefs, and attitudes toward bipolar disorder (BP) in Saudi Arabia (SA).

METHODS

A cross-sectional survey was performed in 2016 in Riyadh, SA. The survey included sociodemographic characteristics and BP awareness scale.

RESULTS

Of 416 participants, 49.5% had prior knowledge of BP, mainly from internet and social media, and 57% considered it to be common in SA. About half believed BP is caused by a neurophysiological or neurochemical imbalance and that it can be treated with psychiatric medications. Supernatural causes, weak faith, and weakness of character were considered causes of BP by 55%, 48%, and 40% of participants, respectively. Recreational activities and head bandaging by traditional therapists were considered viable treatment options by 55% and 41% of participants, respectively. Students and healthcare professionals scored significantly higher on awareness scale. Regarding attitude, a majority believed that persons with BP can work effectively ‎(86%)‎, have to pull themselves together to get over it (47%), and consider it a shame to mention that someone in a family is affected by BP (32%). Regarding relationships, 22% were not willing to maintain a friendship and 39.3% were not willing to marry someone with BP.

CONCLUSIONS

This study revealed suboptimal public awareness towards BP in SA. It identified several misconceptions and negative attitudes toward patients with BP. Further studies are needed to investigate potential public interventions to improve literacy of BP.

Caregivers experiences of nursing care for relatives hospitalized during manic episode: A phenomenological study

PURPOSE

To describe the experiences of informal caregivers with the nursing care received by relatives hospitalized for mania.

DESIGN AND METHODS

Multicenter phenomenological study using open interviews. Data were analyzed using the Stevick-Colaizzi-Keen method.

FINDINGS

The essence of the experiences was the importance of communication, about being informed and involved in treatment during hospitalization of their relative. The experiences depended on the nature of the relation between participant and relative.

PRACTICE IMPLICATIONS

Nurses should listen to caregivers' experiences, inquire about the expectations of caregivers regarding nursing care, and advise informal caregivers on how to take care of their relatives.

Experiences of Mental Healthcare Reported by Individuals Diagnosed with Bipolar Disorder: An Italian Qualitative Study

This qualitative study explores experiences of mental health care by nine Italian users with a diagnosis of bipolar disorder. The findings from semi-structured interviews carried by professional researchers highlighted the following themes: mixed feelings about the diagnosis; lack of access to psychological interventions despite preferences of users; positive view of peer support, job as a safe haven, traumatic experiences of compulsory hospital admissions; need for crisis interventions as alternative to hospital admission. Most users' views look in accordance with evidence-based recommendations seldom implemented in practice. Future research directions, implications of users' expectations and experiences for service planning and quality improvement, are presented and discussed in the light of the qualitative available literature.

Variation of Caregiver Health and Mortality Risks by Age: A Census-Based Record Linkage Study

Due to the focus of studies about caregiving responsibilities on older caregivers, there has been a deficit of research on young caregivers. We aimed to investigate the association between caregiving and health/mortality risk in young caregivers when compared with their noncaregiving peers and older caregivers. A census-based record linkage was implemented, linking all residents enumerated in the 2011 Northern Ireland Census with subsequently registered deaths data, until the end of 2015. Among those aged 5-24 years at the 2011 Census, approximately 4.5% (19,621) of the cohort reported that they were caregivers. The presence of a chronic physical condition (such as mobility difficulties) and/or mental health condition was measured through the Census; all-cause mortality was assessed by official mortality records. Young caregivers were less likely than their noncaregiving peers to report chronic mobility problems (adjusted odds ratio (OR) = 0.84, 95% confidence interval (CI): 0.73, 0.96) but more likely to report chronic poor mental health (adjusted OR = 1.44, 95% CI: 1.31, 1.58). They also differed from older caregivers (P < 0.001) and were at significantly higher mortality risk than their peers (adjusted hazard ratio = 1.54, 95% CI: 1.10, 2.14). A dose-response relationship between hours devoted to caregiving duties and mortality risk was evident. We found that young caregivers were at significantly increased risk of poor health outcomes.

Prevalence and treatment of panic disorder in bipolar disorder: systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression. The literature on panic disorder (PD) comorbid with BD has been systematically reviewed and subject to meta-analysis.

STUDY SELECTION AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were thoroughly followed for literature search, selection and reporting of available evidence. The variance-stabilising Freeman-Tukey double arcsine transformation was used in the meta-analysis of prevalence estimates. Both fixed-effect and random-effects models with inverse variance method were applied to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I2 statistics.

FINDINGS

Overall, 15 studies (n=3391) on cross-sectional prevalence and 25 independent lifetime studies (n=8226) were used to calculate pooled estimates. The overall random-effects point prevalence of PD in patients with BD, after exclusion of one potential outlier study, was 13.0% (95% CI 7.0% to 20.3%), and the overall random-effects lifetime estimate, after exclusion of one potential outlier study, was 15.5% (95% CI 11.6% to 19.9%). There were no differences in rates between BD-I and BD-II. Significant heterogeneity (I2 >95%) was found in both estimates.

CONCLUSIONS

Estimates that can be drawn from published studies indicate that the prevalence of PD in patients with BD is higher than the prevalence in the general population. Comorbid PD is reportedly associated with increased risk of suicidal acts and a more severe course. There is no clear indication on how to treat comorbid PD in BD. Findings from the current meta-analysis confirm the highly prevalent comorbidity of PD with BD, implicating that in patients with BD, PD might run a more chronic course.

Burden on caregivers of older patients with bipolar disorder

OBJECTIVES

Available data suggest high burden on caregivers of patientswith bipolar disorder (BD), yet the well-being of patients with BD increasingly depends on family members, partners and close friends. Aspatients with BD get older, the need for informal care may shift. We aimed to describe the caregivers of older adults with BD (OABD) and explore what patients' and caregivers' characteristics are associated with caregiver burden.

METHOD

Forty-seven caregivers of OABD were questioned about their perceived burden and depressive symptoms. Linear regression analyses were performed to examine the influence of various patients' and caregivers' characteristics on caregiver burden or depression.

RESULTS

More than half of all caregivers experienced some degree of burden,and 6.4% reported depressive symptoms. The number of psychiatric admissions and social functioning were the only patients' characteristics associated with higher burden. Caregiver burden was significantly associated with caregiver's other obligations. None of the patient or caregiver characteristics was significantly associated with depression in caregivers of OABD.

CONCLUSION

In OABD, even with few residual symptoms, more than half of all caregivers experience substantial burden. Future studies are needed to confirm if improving social functioning and preventing psychiatric hospitalizations decrease the burden on the caregivers of OABD.

Randomized, controlled trial of a brief family-centred care programme for hospitalized patients with bipolar disorder and their family caregivers

Family interventions have been emphasized in the treatment of bipolar disorder (BPD) due to the bidirectional and entangled relationships between patients and the family system, and have benefits for patients' symptoms and health; however, the effects of family interventions on family function and caregivers' health-related outcomes have not been well investigated. This randomized, controlled trial with 47 hospitalized patients with BPD/family caregiver dyads at a medical centre in northern Taiwan compared the effects of a brief family-centred care (BFCC) programme with treatment as usual (TAU). All of the family caregivers in two groups were invited to attend a routine 60-min family discussion group about violence and suicide prevention. The TAU group without specific family interview for patient and family caregiver dyad. In the BFCC group, four 90-min BFCC programme sessions were additionally provided twice a week for each hospitalized family dyad. We hypothesized that, first, family caregivers in the BFCC group could increase their family function, and second, improve perceived health status and reduce caregiver's burdens compared to the TAU. The results showed that family caregivers in the BFCC group significant interaction effects in overall family function (P = 0.03) and subscale conflict (P = 0.04), communication (P = 0.01), and problem-solving (P = 0.04), but there were no significant interaction effects on the caregivers' perceived health status and caregivers' burdens. Our findings support both the feasibility of using the BFCC programme for inpatients and its specific benefits for family function. An intensive family intervention during hospitalization has been suggested in psychiatric practice to support patients with BPD and family caregivers.

Novel technology as platform for interventions for caregivers and individuals with severe mental health illnesses: A systematic review

BACKGROUND

Severe mental illnesses (SMIs) have been found to be associated with both increases in morbidity-mortality, need for treatment care in patients themselves, and burden for relatives as caregivers. A growing number of web-based and mobile software applications have appeared that aim to address various barriers with respect to access to care. Our objective was to review and summarize recent advancements in such interventions for caregivers of individuals with a SMI.

METHODS

We conducted a systematic search for papers evaluating interactive mobile or web-based software (using no or only minimal support from a professional) specifically aimed at supporting informal caregivers. We also searched for those supporting patients with SMI so as to not to miss any which might include relatives.

RESULTS

Out of a total of 1673 initial hits, we identified 11 articles reporting on 9 different mobile or web-based software programs. The main result is that none of those studies focused on caregivers, and the ones we identified using mobile or web-based applications were just for patients and not their relatives.

LIMITATIONS

Differentiating between online and offline available software might not always have been totally reliable, and we might have therefore missed some studies.

CONCLUSIONS

In summary, the studies provided evidence that remotely accessible interventions for patients with SMI are feasible and acceptable to patients. No such empirically evaluated program was available for informal caregivers such as relatives. Keeping in mind the influential role of those informal caregivers in the process of treatment and self-management, this is highly relevant for public health. Supporting informal caregivers can improve well-being of both caregivers and patients.

A survey of caregiver burden in those providing informal care for patients with schizophrenia or bipolar disorder with agitation: results from a European study

BACKGROUND

Agitation is a common feature of bipolar disorder and schizophrenia. Previous research indicates that specific symptoms impact caregiver burden in these conditions, but the impact of agitation on caregiver experience is poorly understood. The aim of this study was to characterise caregiver burden in providers of informal care for patients with bipolar disorder and schizophrenia who experience agitation.

METHODS

In total, 297 matched patient and caregiver surveys were collected across the UK, Germany and Spain between October 2016 and January 2017. To be eligible, caregivers needed to provide informal care to a patient with a diagnosis of bipolar disorder or schizophrenia with agitation managed in a community setting and participating in the patient survey. The caregiver survey captured information on demographics and their role in managing the patient's agitation. Caregiver burden was assessed using the Involvement Evaluation Questionnaire. Descriptive analysis was conducted.

RESULTS

Caregivers provided 38.3 h (SD ± 40.34) a week of support to the patient with 20% providing 50 h or more. Most caregivers reported that they recognised an episode of agitation all of the time (44%, n = 130) or sometimes (40%, n = 119). Verbal de-escalation techniques (talking (80%, n = 239) and soothing (73%, n = 218) were the most commonly reported strategies used by caregivers during an episode of agitation; 14% (n = 43) reported resorting to physically restraining the patient. Caregivers supervised rescue medication administration regularly (41%, n = 69) or occasionally (49%, n = 82). Mean Involvement Evaluation Questionnaire score was 32.2 (± 15.27), equivalent to 28.4 (± 13.56) in Germany, 35.6 (± 16.55) in Spain and 33.3 (± 15.15) in the UK. Involvement Evaluation Questionnaire scores were higher for caregivers who reported hostile (41.7 ± 17.07) lack of control (40.3 ± 16.35) and violent (39.5 ± 16.40) patient behaviours when agitated. Over excitement (31.8 ± 15.05), restless (32.6 ± 14.77) and tense (32.9 ± 15.64) behaviours were associated with a lower Involvement Evaluation Questionnaire score.

CONCLUSIONS

Caregivers are active participants in the recognition and management of agitation episodes. The substantial burden reported by these caregivers is impacted by factors including the number of hours of care provided, patient behaviours and country. These may be viable targets for effective interventions to reduce caregiver burden.

Bipolar disorder in Asia: Illness course and contributing factors

BACKGROUND

Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors.

METHODS

A review of the existing literature was done using 'PubMed' and 'Cochrane' databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated.

RESULTS

Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An 'eveningness' chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes.

LIMITATIONS

The effects of treatment and childhood BD course features were not discussed.

CONCLUSIONS

There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.

Caregiver burden in older adults with bipolar disorder: relationship to functionality and neuropsychiatric symptoms

BACKGROUND

There are few studies addressing caregivers of bipolar disorder (BD) patients, especially patients who are older adults with an increased need for care, often given by a relative. The aim of this study was to describe which factors increase caregiver burden among caregivers of elderly BD outpatients.

METHODS

Patients were older than 60 years and met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for BD. They were evaluated for current mood, cognitive and other neuropsychiatric symptoms, functionality, medical comorbidities, quality of life, years since BD diagnosis, and number of psychiatric admissions. The caregiver who spent the greatest time with each patient was evaluated with the Zarit Caregiver Burden Interview. The caregivers' global health, mood symptoms, quality of life, and tasks performed for the patient were also assessed.

RESULTS

Thirty-six BD patients and their caregivers were assessed. The Zarit Caregiver Burden Interview was positively correlated with patients' neuropsychiatric symptoms (r = 0.508, P = 0.002) and functional impairment (r = 0.466, P = 0.004). The Zarit Caregiver Burden Interview was also correlated with caregivers' own depression (r = 0.576, P < 0.001), anxiety (r = 0.360, P = 0.031), quality of life (r = -0.406, P = 0.014), medical comorbidities (r = 0.387, P = 0.020), and number of tasks that they completed for the patient (r = 0.480, P = 0.003).

CONCLUSIONS

In this group of elderly BD patients, caregiver burden was more associated with symptoms frequently seen in others diseases as in dementia than with depressive, manic, or anxiety symptoms, which are often used as treatment outcomes measures goals in BD. Potential treatable and modifiable factors associated with caregiver burden could be caregivers' depression, anxiety, and medical comorbidities, as well as support for caregivers in terms of services and social relationships.

Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

Caregivers of psychiatrically impaired children experience considerable parenting stress. However, no research has evaluated parenting stress within the context of pediatric bipolar spectrum disorders (BPSD). Thus, the aim of this investigation was to identify predictors and moderators of stress among caregivers in the Longitudinal Assessment of Manic Symptoms study. Participants included 640 children and their caregivers in the Longitudinal Assessment of Manic Symptoms cohort. Children had a mean age of 9.4 ± 1.9 years (68% male, 23% BPSD); parents had a mean age of 36.5 ± 8.3 years (84% mothers). Children with BPSD had more service utilization, psychiatric diagnoses, mood and anxiety symptoms, and functional impairment but fewer disruptive behavior disorders. Caregivers of children with BPSD were more likely than caregivers of children without BPSD to have a partner, elevated depressive symptoms, antisocial tendencies, and parenting stress (Cohen's d = .49). For the whole sample, higher child IQ, mania, anxiety, disruptive behavior, and caregiver depression predicted increased parenting stress; maternal conduct disorder predicted lower stress. Child anxiety and disruptive behavior were associated with elevated caregiver stress only for non-BPSD children. Caregivers of children with BPSD experience significant burden and thus require specialized, family-focused interventions. As stress was also elevated, to a lesser degree, among depressed caregivers of children with higher IQ, mania, anxiety, and disruptive behavior, these families may need additional supports as well. Although parents with conduct/antisocial problems evidenced lower stress, these difficulties should be monitored. Thus, parenting stress should be evaluated and addressed in the treatment of childhood mental health problems, especially BPSD.

Burden and Distress in Caregivers of Patients With Panic Disorder and Agoraphobia

We estimated the prevalence, severity, and correlates of burden and distress in caregivers of patients with panic disorder and agoraphobia. The instruments used in this cross-sectional study with 40 caregivers and 40 outpatients were Carer Burden Interview (CBI), Family Burden Interview Schedule (FBIS-BR), Self-Reporting Questionnaire (SRQ), Panic and Agoraphobia Scale (PAS), and Mini-international Neuropsychiatric Interview. Bivariate analyses were followed by regression analyses. The patients' mean PAS score was 29.6, and the mean scores in the caregivers' burden scales were 27 (CBI) and 1.64 (FBIS-BR). Distress (or common mental disorder [CMD]) occurred in 37.5% and was associated with higher burden. In the multivariate analysis, the SRQ score was predicted by female sex and worse self-evaluation of health, the CBI score by CMD and public service, the FBIS-BR score by CMD and not living with the patient, the FBIS-objective score by CMD and being employed, the FBIS-subjective score by CMD, and the level of worry by the severity of patients' avoidance and panic attacks.

Stigma and its correlates among patients with bipolar disorder: A study from a tertiary care hospital of North India

This study aimed to assess stigma and its sociodemographic and clinical correlates among patients with bipolar disorder while in remission. 185 patients currently in remission were assessed on Internalized Stigma of Mental Illness Scale (ISMIS) for internalized stigma, Explanatory Model Interview Catalogue Stigma Scale for perceived stigma and Participation scale for restriction of activities. About 28% patients reported moderate to high level of self stigma as assessed by ISMIS total score. Discrimination experience (38.9%) was reported to be the most commonly experienced self stigma followed by alienation (28.6%) and social withdrawal (28.6%). On the participation scale, about two-fifth (42%) of the participants had severe restriction of activities. Internalized stigma was higher among those with lower age and lesser income. Higher level of stigma was associated with shorter mean duration of remission, income, mean duration of depressive episodes, higher severity of residual depressive symptoms and current level of functioning. Higher internalized stigma was associated with greater restriction in participation of activities. To conclude, present study suggests that self stigma is highly prevalent among patients with bipolar disorder in India and is associated with clinical variables like duration of depressive episodes and level of functioning.

La maladie grave et le deuil vécus en contexte familial : la contribution des modèles théoriques et des démarches intégratives à l’avancement des recherches

Nombreux sont les travaux contemporains qui portent sur les aspects théoriques, méthodologiques et empiriques des problématiques entourant la maladie grave et le deuil vécus en contexte familial. Ce texte se propose de faire le point sur les perspectives théoriques, qui se recoupent à plusieurs reprises dans ces deux domaines, à partir d’une recension des travaux contemporains. On retrouve ainsi des modèles théoriques, essentiellement sociologiques et psychosociaux, qui peuvent être regroupés selon les catégories suivantes : approches qualitatives inductives qui conduisent à des modèles intégrateurs ; approches hypothético-déductives qui prennent en considération des facteurs spécifiques organisés en modèles et vérifiés à partir d’approches quantitatives et de procédures statistiques. À ces perspectives théoriques viennent s’ajouter les apports des approches systémiques, celles de la résilience, de l’ajustement au deuil et la construction du sens, de même que celles qui privilégient une démarche intégrative comme le modèle du double processus d’ajustement au deuil. Ce survol des fondements théoriques, des concepts et des principales hypothèses permet de démontrer la richesse de ces travaux et leur contribution à la compréhension des réseaux familiaux confrontés à des crises majeures qui demandent une réorganisation des configurations relationnelles et de trouver des ressources adaptatives pour traverser ces moments difficiles.

Influence of religion and supernatural beliefs on clinical manifestation and treatment practices in patients with bipolar disorder

BACKGROUND

Religious and supernatural beliefs influence help seeking and treatment practices in bipolar disorder, but these are rarely explored by clinicians. This study aimed to understand religiousness, magico-religious beliefs, prevalence of religious and supernatural psychopathology and treatment practices among patients with bipolar disorder in euthymic state.

METHODOLOGY

A total of 185 patients of bipolar disorder currently in remission were assessed cross-sectionally for their clinical profile, current clinical status on the Hamilton Depression Rating Sscale (HDRS), Young Mania Rating Scale (YMRS) and the Global Assessment of Functioning (GAF). A semi structured instrument for magico-religious beliefs, aetiological models, treatment seeking and treatment practices was administered.

RESULTS

More than a third of patients (37.8%) had psychopathology with either religious or supernatural content or both in their lifetime. Almost half (45.4%) the patients believed in a supernatural/religious aetiology for their illness. Among the specific causes, planetary influences (13.5%) and God's will (30.8%) were the most common supernatural and religious cause, respectively. Almost half (44.3%) of patients had first treatment contact with religious/supernatural treatment providers. More than 90% of patients reported belief in God, yet about 70% reported that their doctors did not ask them sufficient questions to understand their religiosity.

CONCLUSION

Magico-religious beliefs are common in bipolar disorder and a large number of patients attribute these as aetiological factors for their illness. Consequently they tend to seek treatment from traditional practitioners prior to approaching medical practitioners and may continue treatment with them alongside medical management.

Efficacy of repetitive transcranial magnetic stimulation with quetiapine in treating bipolar II depression: a randomized, double-blinded, control study

The clinical and cognitive responses to repetitive transcranial magnetic stimulation (rTMS) in bipolar II depressed patients remain unclear. In this study, thirty-eight bipolar II depressed patients were randomly assigned into three groups: (i) left high-frequency (n = 12), (ii) right low-frequency (n = 13), (iii) sham stimulation (n = 13), and underwent four-week rTMS with quetiapine concomitantly. Clinical efficacy was evaluated at baseline and weekly intervals using the 17-item Hamilton Depression Rating Scale (HDRS-17) and Montgomery-Asberg Depression Rating Scale (MADRS). Cognitive functioning was assessed before and after the study with the Wisconsin Card Sorting Test (WCST), Stroop Word-Color Interference Test (Stroop), and Trail Making Test (TMT). Thirty-five patients were included in the final analysis. Overall, the mean scores of both the HDRS-17 and the MADRS significantly decreased over the 4-week trial, which did not differ among the three groups. Exploratory analyses revealed no differences in factor scores of HDRS-17s, or in response or remission rates. Scores of WCST, Stroop, or TMT did not differ across the three groups. These findings indicated active rTMS combined with quetiapine was not superior to quetiapine monotherapy in improving depressive symptoms or cognitive performance in patients with bipolar II depression.

Feasibility of a psychoeducational family intervention for people with bipolar I disorder and their relatives: Results from an Italian real-world multicentre study

BACKGROUND

Despite several guidelines recommend the use of psychoeducational family interventions (PFIs) as add-on in the treatment of patients with bipolar I disorder, their implementation on a large scale remains limited. The aim of the present study is to identify obstacles for the feasibility of PFIs in routine care.

METHODS

This was a multicentre, real-world, controlled, outpatient trial, carried out in 11 randomly recruited Italian mental health centres. Two mental health professionals from each center attended a modular training course on PFI and provided the intervention. Difficulties and benefits experienced by mental health professionals in implementing the intervention were assessed through the Family Intervention Schedule (FIS-R), which was administered six times.

RESULTS

Sixteen out of the 22 recruited professionals completed the training and administered the PFI to 70 patients with bipolar I disorder and their relatives. The retention rate of families receiving the intervention was 93%. Mental health professionals reported high levels of organizational difficulties, several benefits in their daily clinical work and low levels of intervention-related difficulties. The most important organizational obstacles were related to the need to integrate the intervention with other work responsibilities and to the lack of time to carry out the intervention. These difficulties did not decrease over time. Intervention-related difficulties were rated as less problematic since the first time assessment and tended to improve over time.

LIMITATIONS

Low number of recruited professionals; use of a not previously validated assessment instrument.

CONCLUSIONS

PFIs are feasible in routine care for the treatment of patients with bipolar I disorder and their relatives, and main obstacles are related to the organization/structure of mental health centres, and not to the characteristics of the intervention itself.

Family caregiver burden in mental illnesses: The case of affective disorders and schizophrenia - a qualitative exploratory study

BACKGROUND

Caregivers of people with mental illnesses often experience a wide range of burdens. Although many studies have confirmed burdens among family caregivers of mentally ill relatives in general, specific knowledge regarding the concrete everyday hassle and existential sorrows from the caregiverś subjective reasoning perspective is lacking. Furthermore, there is little evidence on the possible different effects of affective disorders and schizophrenia on the quality of burden; this is also true with regard to the role of cultural traditions and lay beliefs.

AIMS

The aim of this study was to explore the specific burdens experienced by caregivers of patients with schizophrenia and affective disorders.

METHODS

A qualitative study was conducted by semi-structured interviews with 45 caregivers of patients with schizophrenia and affective disorders. Data were analysed by qualitative content analysis.

RESULTS

Eleven encumbering themes resulted from the interviews including incertitude, unawareness, emotional burden, stigma and blame, financial burden, physical burden, restriction in routine, disruption in routine, dissatisfaction with family, relatives, and acquaintances, troubles with patients' adherence to medication, and problems with health services and governmental support.

CONCLUSIONS

Caring for a person with mental illness affects caregivers emotionally, financially, physically, and it elicits some restrictions in their routine (daily hassles). Finally, it causes conflicts in family relationships. Despite some differences regarding perceived burden among caregivers of schizophrenia and affective disorders, a common pattern of burden could be identified. Thus, authorities should provide adequate financial, educational, and psychosocial supports for caregivers of mental illnesses.