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Psychosocial disability in the Course of Bipolar I and II

By Judd LL, Akiskal HS, Schettler PJ, Endicott J, Leon AC, Solomon DA, Coryell W, Maser JD, Keller MB.

From Arch Gen Psychiatry. 2005 Dec;62(12):1322-30.

Summaries and Important Issues addressed in this Article

Brief Outline of how this study was conducted:

  • This is a prospective, comparative, longitudinal, naturalistic study which recruited patients from both inpatient and outpatient at 5 US centres
  • 158 of BPI and 133 BP II were recruited using the Research Diagnostic Criteria, (with no organic psychiatric disorders), whom were FU for a mean of 15 years. The control group were 1817 relatives whom did not have any psychiatric disorder
  • Trained professional raters interviewed pts every 6months for the first 5 yrs and then yearly thereafter
  • Psychiatric symptom rating scale employed: LIFE(Longitudinal Interval FU Evaluation)-RIFT score(Range of Impaired Functioning Tool) was obtained for every month from 25mo to 5 yrs of FU and for the final month of FU in yrs 6-20
  • Random regression analysis (using SAS MIXREG software) was used to model the relationship between LIFE-RIFT ratings of psychosocial impairment and monthly severity and polarity of affective symptoms

Four important questions addressed in this article concerning about the psychosocial disability:

  1. Does psychosocial disability increase significantly with each increment of symptom severity?
    1. In both BPI and BPII, each increase or decrease in depressive symptom severity is associated with a highly significant stepwise increase or decrease in psychosocial disability
    2. In BPI, significant change in impairment as their level of manic symptom severity changes between mild subsyndromal symptom and hypomania or between hypomania and mania. No significant change between subsyndromal hypomanic symptom and asymptomatic state
    3. In BPII, no significant change in psychosocial impairment when severity change from asymptomatic to subsyndromal hypomanic to hypomanic symptom. Only slight but non-significant improvement in psychosocial functioning when going from asymptomatic to subsydromal hypomanic symptom
  2. Are symptoms and signs (s/s) in manic spectrum associated with more psychosocial disability than s/s in depressive spectrum at corresponding level of severity?
    1. In BPI, minor depression is associated with significantly more psychosocial disability than hypomania
    2. In BPII, subsyndromal depressive symptoms are more disabling than subsyndromal hypomanic s/s and minor depressive s/s are more disabling than hypomanic symptom
    3. Therefore, at each level of depressive symptom severity, psychosocial impairment is equal to or significant greater than the corresponding level of manic symptom severity in BPI and BPII
  3. Is BP II less impairing than BP I at corresponding level of severity?
    1. While experiencing hypomanic symptom, patient with BPII have significant better psychosocial function than patient with BPI
    2. No difference in psychosocial impairment between BPI and BPII at any level of depressive symptom severity or asymptomatic status
  4. Do patients return to good psychosocial functioning when they completely free of s/s and compare with well-control group?
    1. Patient with BPI and BPII at each level of depressive symptom severity are significantly more impaired than well control group
    2. In BPI, each level of manic or hypomanic symptom is associated with significant greater impairment than in well comparison group
    3. In BPII, no significant impairment in patients with hypomanic or subsyndromal hypomanic symptom

Conclusions and Implication in our daily practice

  1. Depressive symptom in both BP subtypes are at least as disabling as, and sometimes more disabling than corresponding levels of manic or hypomanic symptom
  2. There is a need for greater attention to depressive symptom in diagnosis and Treatment since most Tx has focused on Management of more dramatic manic episodes but not on depression
  3. BPII is comparable to BPI in terms of psychosocial disability at corresponding levels of affective s/s severity
  4. Only during hypomania in BPI patients are more significantly impaired than BPII patients owing to non-significant improvement in psychosocial function of BPII during subsyndromal hypomania vs asymptomatic
  5. This highlights an important difference in psychosocial functioning between BPI and BPII. Hypomania in BPII presents not only a diagnostic challenge but also a therapeutic challenge
  6. When pts with BPI and BPII are asymptomatic, their psychosocial function is good but not as good as that of well control
Resources Centre Literature Review Psychosocial disability in the Course of Bipolar I and II