Bipolar Disorder: The Importance of Quality-of-Life Outcomes

ABSTRACT: Patients with bipolar disorder regularly experience poorer outcomes in a variety of areas than do unaffected persons. Until recently, there was little research specifically focusing on qualityof- life issues in patients with bipolar disorder. Such research is increasing, however, with interesting results. Researchers have found that the quality of life of patients with bipolar depression is worse than that of patients with unipolar depression; that contrary to long-held ideas associating mania with an increased sense of wellbeing, patients with mania or hypomania rate their quality of life as lower than or the same as that of patients who are euthymic; also, that weight gain in patients with bipolar disorder is associated with lower quality of life. Historically, the success of treatment for bipolar disorder has been gauged by a decrease in symptoms rather than by improvement in function or quality of life. However, many patients exhibit poor role-function adjustment despite adequate mood stabilization. Functional outcomes may thus be more meaningful gauges of response to treatment. Controlled clinical trials have now begun to include quality-of-life measures. The National Institute of Mental Health Life Chart can help clinicians assess the quality of life of patients with bipolar disorder. ___________________________________________________________________________________________________________ Any clinician who has had patients with bipolar disorder will readily agree that the quality of life of such patients is quite poor. Until recently, however, there was little research to confirm this instinctive observation, let alone to quantify or analyze these patients’ quality-of-life deficit. And without such research to serve as a foundation, efforts to improve quality of life for patients with bipolar disorder are often shots in the dark. Fortunately, research in this area is increasing. This article identifies the various tools available to help assess quality of life and explores the findings to date about the quality of life in patients with bipolar disorder. Perhaps most important, it examines the disparity between symptom remission and functional quality-of-life outcomes—a gap that calls into question accepted measures of the success of bipolar treatment. Finally, a tool is presented for assessing and monitoring quality of life of the patients in your practice who have bipolar disorder. SIGNIFICANT IMPAIRMENT IN MANY AREAS A 2004 survey by Morselli and colleagues1  is typical of the recent and growing body of research on quality of life in patients with bipolar disorder. The study, which involved 968 patients with bipolar disorder from 8 European countries, showed that the disease is associated with very high unemployment rates and that it results in patients’ negative perceptions of quality of life both within and outside the family. The researchers found these patterns to be the same among patients of all nations and still noticeable despite recent improvements in patient insight and compliance. They concluded that much remains to be done to improve the social functioning and social integration of patients with bipolar disorder. Patients with bipolar disorder regularly experience poorer outcomes than do unaffected persons in a variety of areas. These include: • Life expectancy. • Physical health. • Mental health. • Job performance. • Financial status. • Personal and family relationships. • Social life. Both life expectancy and physical health are severely compromised. Osby and colleagues2  studied mortality and cause of death in 15,386 Swedish patients with bipolar disorder who were monitored from the time of hospital diagnosis for an average of 10 years. Their findings confirmed the increased rates of suicide and violent death that had previously been recognized in patients with bipolar disorder. In addition, the researchers found that about half the excess deaths were attributable to natural causes and that the standardized mortality ratios were increased for all natural causes of death (Figure 1). These data indicate that the physical health of patients with bipolar disorder is compromised in many ways. Bipolar disorder takes an especially heavy toll on job performance. Patients who have the disorder are frequently absent or on disability leave. Goetzel and colleagues3  analyzed data on 374,799 employees from 6 large employers. An analysis of the costs to employers of absenteeism and disability, as well as the direct costs of treatment, showed that bipolar disorder was more costly to business than any other mental disorder. TOOLS TO ASSESS QUALITY OF LIFE—AND WHAT THEY SHOW Various instruments have been developed to assess quality of life in patients with bipolar disorder and other mental illnesses. Some of these are listed in Table 1.  Such instruments are being used with increasing frequency to research the quality of life of patients with bipolar disorder. Some of the results of this research are surprising. Yatham and colleagues,4  using the Short Form 36 (SF-36), found that on 4 subscales of quality of life (general health, social functioning, physical role, and emotional role), patients with bipolar depression fare worse than do patients with unipolar depression (Table 2). Mania and hypomania have traditionally been defined as states characterized by euphoric mood and a sense of increased well-being. However, there were few data on self-perceived quality of life of patients in a manic or hypomanic state to either confirm or deny this assumption. A growing body of evidence indicates that mania and hypomania are characterized by significant dysphoric symptoms. For example, Vojta and colleagues5 used 2 different instruments—the Short Form 12 (SF-12) and the EuroQol visual analog scale “thermometer”—to quantify self-perceived quality of life in 86 patients with bipolar disorder. They found that patients with mania or hypomania rated their quality of life as lower than or the same as that of patients who were euthymic (Table 3). Several recent studies have shown that weight gain is associated with lower quality of life in patients with bipolar disorder. In a cross-sectional comparison study, Meletiche and colleagues6  used the Psychological General Well-Being (PGWB) Scale to assess quality of life in 377 patients with bipolar disorder. Fortyfive percent of the patients reported weight gain (6 lb or more over the previous 6 months). Those who reported weight gain had significantly lower scores on the PGWB than did those who had not gained weight (47.4 vs 53.2; P  = .015). In fact, a special instrument has been developed specifically for assessing the effect of weight gain on quality of life. The Impact of Weight on Quality of Life–Lite (IWQOL-Lite) Measure is a 31-item, validated selfreport measure of weight-related quality of life.7  In addition to a total score, it provides scores in 5 distinct domains: physical function, self-esteem, sexual life, public distress, and work. Studies using the IWQOL-Lite show that excess weight has a substantial negative impact on the quality of life of patients with bipolar disorder (Figure 2 ).7 Many of the mood stabilizers and antidepressants used in the treatment of bipolar disorder have weight gain as an adverse effect. This fact contributes to the frequently encountered clinical dilemma of stabilizing mood at the expense of weight control. Increasingly, it is important to recognize when a treatment is likely to contribute to weight gain and whether, despite its positive impact on mood, it may unmask, exacerbate, or complicate other medical comorbidities, such as hypertension, diabetes, and dyslipidemia—and may have only a minimal net effect on quality of life. Additional research into the quality of life of patients with bipolar disorder is still needed. In particular, the quality of life of patients in specific mood states—manic/hypomanic, depressed, and euthymic—deserves focused study. FUNCTIONAL RECOVERY VERSUS SYMPTOM AMELIORATION Historically, the success of treatment of bipolar disorder has been gauged by a decrease in symptoms rather than by an improvement in function or quality of life. In fact, FDA registrational trials have focused exclusively on efficacy, with “response” defined as a 50% reduction in symptoms as demonstrated by the Young Mania Rating Scale, Montgomery-Asberg Depression Rating Scale, or a similar instrument. Quality-of-life outcomes were not required, and until recently, were seldom assessed. However, in bipolar disorder, there is a significant disparity between symptomatic and functional measures of response to treatment. A number of studies document poor role-function adjustment despite adequate mood stabilization. In one prospective study, Dion and colleagues8  evaluated patients with bipolar disorder 6 months after hospitalization for a manic episode. Almost 80% of the patients were symptom-free or only mildly symptomatic. However, only 43% were employed and only 21% were working at their expected level; 30% were judged incapable of working. Tohen and colleagues9  compared syndromal recovery and functional recovery after first hospitalization in 219 patients who had major affective disorders with psychotic features (Figure 3). Syndromal recovery was defined as no longer meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) episode criteria. Functional recovery was defined as regaining baseline vocational and residential status. The authors found that functional recovery was 2.6 to 2.7 times less likely than syndromal recovery and that 63.1% of patients who achieved syndromal recovery still had not recovered functionally at 2 years. Quality of life is significantly compromised even in patients with bipolar disorder who achieve euthymia. Robb and colleagues10 assessed the extent and pattern of illness intrusiveness (one measure of quality of life) in 68 patients with bipolar disorder who met criteria for euthymia. They found that the study participants experienced significant illness intrusiveness in a number of life domains, even after the investigators controlled for negative life events. In fact, the degree of total illness intrusiveness experienced by patients with bipolar disorder was found to be similar to that of persons with multiple sclerosis and greater than that of patients with end-stage renal disease. Thus, evidence is accumulating that functional outcomes are more meaningful gauges of response to treatment of bipolar disorder than are scores on psychiatric rating scales used to assess improvement in symptoms. Controlled clinical trials have now begun to include quality-of-life measures. Clinicians, too, need to be concerned with such real-world measures as: • Whether a patient is working (and whether this is at home or in an office). • Whether a patient is working with premorbid productivity. • Whether social contacts have been reinstated. • Whether interpersonal relationships are moving forward. A TOOL TO HELP TRACK THE QUALITY OF LIFE OF YOUR PATIENTS The National Institute of Mental Health (NIMH) Life Chart Method is a readily available tool that can help clinicians assess the quality of life of their patients who have bipolar disorder. The key to the NIMH Life Chart Method is a chart (Figure 4) on which patients are asked to enter information each day on the presence of manic and depressive symptoms and on the degree of functional impairment that they experience in their usual educational, social, or occupational roles. On the basis of this information, clinicians can characterize each day in terms of the severity of the illness. Because the chart also tracks medications, the effects of a treatment regimen on functional outcomes is thrown into sharp relief. The NIMH Life Chart also allows for integration of the effects of life events, and it can be used to help identify prodromal symptoms, which permits early—and thus more effective—treatment of episodes. The average time commitment required of a patient to complete the daily data entry is less than that needed for other longterm monitoring methods that have been used in the treatment of bipolar disorder (such as the Adjective Mood Scale, the Social Rhythm Metric, or the Kraepelin color-coded life chart).11 Overall, the NIMH Life Chart Method was found to be the most useful and to require the least effort on the part of patients.11  Dr Frye is associate professor of psychiatry at the David Geffen School of Medicine at the University of California at Los Angeles (UCLA) and director of the UCLA Bipolar Disorder Research Program. REFERENCES: 1. Morselli PL, Elgie R, Cesana BM. GAMIANEurope/BEAM survey II: cross-national analysis of unemployment, family history, treatment satisfaction and impact of the bipolar disorder on life style. Bipolar Disord. 2004;6:487-497. 2. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58:844-850. 3. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large US employers in 1999. J Occup Environ Med. 2003;45:5-14. 4. Yatham LN, Lecrubier Y, Fieve RR, et al. Quality of life in patients with bipolar I depression: data from 920 patients. Bipolar Disord. 2004;6:379-385. 5. Vojta C, Kinosian B, Glick H, et al. Self-reported quality of life across mood states in bipolar disorder. Compr Psychiatry. 2001;42:190-195. 6. Meletiche DM, Bolge S. Impact of weight gain on HRQL of bipolar patients. Presented at: the 5th International Conference on Bipolar Disorder; June 12-14, 2003; Pittsburgh. 7. Corey-Lisle PK, et al. Bipolar disorder: relationship between body mass index and quality of life. NR321. Presented at: the 158th Annual Meeting of the American Psychiatric Association; May 21-26, 2005; Atlanta. 8. Dion GL, Tohen M, Anthony WA, Waternaux CS. Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hosp Community Psychiatry. 1988;39:652-657. 9. Tohen M, Hennen J, Zarate CM Jr, et al. Twoyear syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry. 2000;157:220-228. 10. Robb JC, Cooke RG, Devins GM, et al. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatr Res. 1997;31:509-517. 11. Shärer LO, et al. Evaluation of long-term monitoring methods for bipolar patients. Presented at: the 4th International Conference on Bipolar Disorder; June 14-16, 2001; Pittsburgh.