|Year : 2018 | Volume
| Issue : 1 | Page : 37-41
Disability in bipolar affective disorder patients in relation to the duration of illness and current affective state
RS Swaroopachary1, Lokesh Kumar Kalasapati2, Sarath Chandra Ivaturi1, C M. Pavan Kumar Reddy3
1 Department of Psychiatry, SVS Medical College, Mahabubnagar, Telangana, India
2 Department of Psychiatry, Bhaskar Medical College, Hyderabad, Telangana, India
3 Department of Psychiatry, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Web Publication||26-Jun-2018|
Dr. R S Swaroopachary
Department of Psychiatry, SVS Medical College, Mahabubnagar - 509 001, Telangana
Source of Support: None, Conflict of Interest: None
Background: Bipolar affective disorder (BPAD) is an episodic illness in which episodes of depression/Mania/Mixed/Hypomania occur. BPAD has been found to be associated with the following types of disability: increased suicidal behavior, higher unemployment, higher dependence on public assistance, lower annual income, and increased work absenteeism owing to illness, decreased work productivity, poorer overall functioning, lower quality of life, and decreased lifespan. The two affective disorders, major depressive disorder, and bipolar disorders were associated with the large decrements in functioning. Bipolar disorder was particularly strongly associated with having missed time at work. Depressive disorders have been associated with a larger number of disability days and poorer role functioning than several common general medical diseases – arthritis, hypertension, and diabetes.
Aims: This study aims to study the disability in bipolar patients in relation to the duration of their illness and current effective state.
Methodology: Clinical and sociodemographic details of patients and caregivers were collected using a semi-structured pro forma. Indian Disability Evaluation and Assessment Scale is used to assess patients' disability. The diagnosis of BPAD is made in accordance with the International Classification of Disease-10 criteria.
Results: Severe disability is seen where the duration of illness is <10 years. Among depressive patients, the disability is found to of moderate level whereas patients who have a current manic episode experienced severe disability.
Conclusions: Severe disability is seen where the duration of illness is <10 years.
Keywords: Bipolar affective disorder, current effective state, duration of illness
|How to cite this article:|
Swaroopachary R S, Kalasapati LK, Ivaturi SC, Reddy C M. Disability in bipolar affective disorder patients in relation to the duration of illness and current affective state. Arch Ment Health 2018;19:37-41
|How to cite this URL:|
Swaroopachary R S, Kalasapati LK, Ivaturi SC, Reddy C M. Disability in bipolar affective disorder patients in relation to the duration of illness and current affective state. Arch Ment Health [serial online] 2018 [cited 2018 Dec 14];19:37-41. Available from: http://www.amhonline.org/text.asp?2018/19/1/37/235321
| Introduction|| |
Bipolar affective disorder (BPAD) is an episodic illness in which episodes of depression/Mania/Mixed/Hypomania occur. BPADs are dimensional illnesses in which patients' experience, during long-term course of illness, fluctuating levels of severity of manic and depressive symptom interspersed with symptom-free (euthymic) periods. The current prevalence of (BPAD) is 0.4%–0.5%, 1-year prevalence is 0.5%–1.4% and lifetime prevalence is 2.6%–7.8%. In India, the prevalence of affective disorder ranges from 0.51 per thousand population  to 20.78 per thousand population.
Physical functioning refers to the ability of an individual to carry out daily activities such as dressing and bathing, the capacity to perform physical tasks such as exercise, and the extent of any restriction in physical activity such as partial or complete days of rest in bed (bed days)., Measures of physical functioning, such as disability days, are commonly used as indicators of the need for services in health policy services and planning or allocating services. These measures are assumed to reflect physical rather than psychiatric problems., Long-term outcome studies have found that nearly one-third of manic patients have poor work performance and adjustment in other areas at 30 years' follow-up. It has been reported that, on an average, a women with onset of the illness at 25 years of age may lose 9 years of life, 12 years of normal health, and 14 years of effective functioning without sufficient treatment. De Lisio et al. reported disruption in work and leisure, particularly in aspects requiring personal initiative that remained abnormal well into the inter episodic phase following a depressive episode. Social maladjustment and incapacity to enjoy leisure time are also common.
The two affective disorders, major depressive disorder and bipolar disorders were associated with the large decrements in functioning. Bipolar disorder was particularly strongly associated with having missed time at work. Chaudhury et al. used Indian Disability Evaluation and Assessment Scale (IDEAS) for 228 psychiatric patients of whom 30 patients were diagnosed as bipolar disorder. In BPAD patients all the core areas of functioning such as self-care, interpersonal relations, communication and understanding, and work were affected.
- To study the sociodemographic variables among the present study population
- To compare the age of onset of illness with the disability in patients
- To correlate the duration of illness with disability among the patients
- To study the correlation between current episode of illness with the disability experienced.
| Methodology|| |
This is a cross-sectional hospital-based study. The study was conducted in the Inpatient Department of Psychiatry, S. V. S Medical College and Hospital. This is a tertiary care hospital, providing specialist clinical care to Mahabubnagar and adjoining districts. The present study was conducted for 6 months, i.e. from November 1, 2016, to April 30, 2017. The study sample was collected from patients admitted for BPAD and their caregivers. Patients were selected consecutively. The study sample consisted of seventy patients diagnosed to have BPAD and their respective caregivers.
Patients fulfilling the selection criteria were approached, and informed consent was obtained. Clinical and sociodemographic details of patients and their caregivers were collected using a semistructured pro forma. Patients were administered the IDEAS  to assess their disability. Assessments were cross-sectional and nonblind. The diagnosis of BPAD is made in accordance with the International Classification of Disease-10 criteria.
Criteria for selection
- Inclusion criteria were as follows: Availability of caregivers
- Age of patient and the caregiver should be >16 years
- Both should be physically fit to answer the questions.
Exclusion criteria were as follows:
- Patients and their caregivers taking any medication, which can produce cognitive and other psychological defect
- Patients and their caregivers with other comorbid general medical condition, those needing urgent attention for physical problems
- Patients without caregivers who can give reliable and adequate information
- Those who did not give consent for the study.
| Results|| |
[Table 1] Shows the sociodemographics of the patient group.
|Table 1: Sociodemographic variables in patients of bipolar affective disorder|
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The total study sample consists of 60 patients. The mean age of patients is 33.97 ± 9.8. There is almost equal distribution of males and females. With reference to education the sample were divided into four categories, illiterate, <5 years, 6–10 years, and >10 years. Most of them are either illiterate or having <10 years of formal education.
Majority of the patients were unemployed. Depending on the family income patients were divided into four categories – <5,000 Rs per month, 5,000–10,000 Rs per month, 10,000–15,000 Rs per month, and more than 15,000 Rs per month. Majority of the patients were in the category of <10,000 Rs per month. Majority of the patients belonged to nuclear family. Majority were from the urban locality.
Age of onset of illness is divided into three categories as 11–20 years, 21–30 years, and above 30 years. As shown in [Table 2], it is found that all the patients above 30 years have moderate disability (100%) and severe disability is more prevalent in the adolescent age group (11–20 years) of patients than in others.
|Table 2: Comparison of age of onset of illness with disability in bipolar affective disorder patients|
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[Table 3] shows the correlation between the disability and duration of illness in the BPAD patients. Patients are divided into three groups basing the duration of illness as 0–10 years, 11–20 years, and >20 years. We found that all the patients with duration of illness between 11 and 20 years and above 20 years had moderate disability and severe disability is more common in patients with duration of illness <10 years.
|Table 3: Correlation of duration of illness with disability in bipolar affective disorder patients|
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In [Table 4], the severity of the disability is correlated with the current episode of bipolar illness. Moderate disability is more prevalent in depressive patients (90%), and severe disability is found more commonly found in patients who are in manic episode (10%) than those in depressive episode. However, the correlation is not statistically significant (P = 0.33).
|Table 4: Correlation of current episode with disability in bipolar affective disorder patients|
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| Discussion|| |
Patients within the age group of 11–20 years had more disability when compared to other age groups. This finding is similar to that of Goldstein et al. who in his study on bipolar disorders has observed that bipolar youth in-episode were significantly more impaired than those in partial remission/recovery in every functional domain examined and were less satisfied with their functioning. Yet, BP youth in partial remission/recovery reported significant psychosocial impairment.
Patients who are currently in manic episode have more disability than those who are in depressive phase. Depressive episodes and symptoms, which dominate the course of BPAD-I and BPAD-II, are equal to or more disabling than corresponding levels of manic or hypomanic symptoms; subsyndromal depressive symptoms, but not subsyndromal manic or hypomanic symptoms, are associated with significant impairment. BP-I patients were completely unable to carry out work role functions during 30% of assessed months, which was significantly more than for UP-MDD and BP-II patients (21% and 20%, respectively).
Allen and Allen reported that disabilities restrict performance of social roles; limit the ability of the patient to function at expected levels; and often the signal that disease exists that requires diagnosis and treatment. The physical functioning of the person with psychiatric disorders is of clinical interest for several reasons. First, grave disability is a common indication for inpatient psychiatric admission. Second, physical limitations may be inappropriately attributed to medical rather than psychiatric problems by the patient and health-care providers. Third, limitation in physical functioning affects patients' choice of mental health-care provider (General Medical vs. Mental Health Specialist).
Several psychiatric diagnoses were associated with limitation in physical functioning. The largest effects were for affective disorder, particularly major depression.
Mental illness was recognized as one of the causes of disability in an Act passed by the government of India. This act known as Persons with Disabilities Act was enacted in 1995. It came into force from February, 1996. Sanderson and Andrews found that disability was significantly greater among participants with current psychiatric diagnoses and disability varied by type of disorder. Disorders found to be independently associated with disability were depression, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, alcohol dependence, and drug dependence.
BPAD has been found to be associated with the following types of disability: Increased suicidal behavior, higher unemployment, higher dependence on public assistance, lower annual income, increased work absenteeism owing to illness, decreased work productivity, poorer overall functioning, lower quality of life, and decreased lifespan. Chaudhury et al. found that patients having BPAD were disabled in the following cores of functioning: Self-care, interpersonal relations, communication, and understanding and work.
Depressive disorders have been associated with a larger number of disability days and poorer role functioning than several common general medical diseases – arthritis, hypertension, and diabetes. It is estimated that approximately 60%–80% of those diagnosed with bipolar disorder will respond to treatment and of the total affected 15% will commit suicide during the course of their illness.
Robb et al. administered Illness Intrusiveness Rating Scale on 68 bipolar patients. The most highly disrupted domains were self expression, self-improvement, family relationships, social relationships, and work. Moderately affected domains included financial situation, marital relations, sex life, active recreation, health and diet. Least affected life domains were passive recreation, religious expression, and community and civic involvement.
| Conclusions|| |
- The mean age of patients is 33.97 ± 9.8 with almost equal prevalence among both the genders
- Most of them had the years of education between 5 and 10 years. Majority of the patients were unemployed, having a monthly income of <10,000 Rs per month. Many are living in nuclear families and were hailing from urban community
- Patients falling in the age group of 11–20 years were experiencing severe disability
- Severe disability is seen where the duration of illness <10 years
- Among depressive patients, the disability is found to of moderate level whereas patients who have a current manic episode experienced severe disability.
- The time-bound nature of the study dictated a small sample size
- Restricted nature of sample means that the findings are not readily applicable to other population
- Assessment was cross-sectional and nonblind
- Those patients who did not/never attend OPD were obviously out of study
- On direct enquiry, there could be chances of wrong information
- Several factors such as copying and expressed emotions were not assessed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Judd LL, Akiskal HS, Schettler PJ, Endicott J, Leon AC, Solomon DA, et al.
Psychosocial disability in the course of bipolar I and II disorders: A prospective, comparative, longitudinal study. Arch Gen Psychiatry 2005;62:1322-30.
Rihmer Z, Angst J. Mood disorders: Epidemiology. In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 8th
ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 1575-81.
Dube KC. A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh – India. Acta Psychiatr Scand 1970;46:327-59.
Trivedi S, Chandrashekaran R, Venugopalan M. An Epidemiologic Study of Psychiatric Morbidity in Rural Area of Pondicherry. Abstracts 41st
annual Conference of Indian Psychiatric Society; 1988.
Wilder CS. Health Characteristics of Persons with Chronic Activity Limitation: Data from the National Health Survey, Series 10, Number 112: Department of Health, Educational and Welfare publication HRA77-1539. Rockville MD: National Center for Health Statistics; 1976.
Stewart AL, Ware JE Jr., Brook RH. Advances in the measurement of functional status: Construction of aggregate indexes. Med Care 1981;19:473-88.
Manning WG, Newhouse JP, Ware JE. Beyond excellent, good, fair, poor, in economic aspects of health. In: Fuchs VR, editor. The Status of Health in Demand Estimation. Chicago: University of Chicago Press; 1982.
Wilson RW, Drury TF. Interpreting trends in illness and disability: Health statistics and health status. Annu Rev Public Health 1984;5:83-106.
Tsuang MT, Woolson RF, Fleming JA. Long-term outcome of major psychoses, I: schizophrenia and affective disorders compared with psychiatrically symptom free surgical conditions. Arch Gen Psychiatry 1979;39:1295-1301.
Medical Practice Project. A State-of-the Science Report for the Office of the Assistant Secretary for the US Department of Health, Education Welfare Baltimore; 1979.
De Lisio G, Maremmani I, Perugi G, Cassano GB, Deltito J, Akiskal HS, et al.
Impairment of work and leisure in depressed outpatients. A preliminary communication. J Affect Disord 1986;10:79-84.
Perugi G, Maremmani I, McNair DM, Cassano GB, Akiskal HS. Differential changes in areas of social adjustment from depressive episodes through recovery. J Affect Disord 1988;15:39-43.
Olfson M, Fireman B, Weissman MM, Leon AC, Sheehan DV, Kathol RG, et al.
Mental disorders and disability among patients in a primary care group practice. Am J Psychiatry 1997;154:1734-40.
Chaudhury PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95-101.
] [Full text]
Rehabilitation Committee of the Indian Psychiatry Society IDEAS (Indian Disability Evaluation and Assessment Scale). Kolkata: IPS; 2002.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorder, Tenth Revision. Geneva: World Health Organization; 1992.
Goldstein TR, Birmaher B, Axelson D, Goldstein BI, Gill MK, Esposito-Smythers C, et al.
Psychosocial functioning among bipolar youth. J Affect Disord 2009;114:174-83.
Judd LL, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: Re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord 2003;73:123-31.
Judd LL, Schettler PJ, Solomon DA, Maser JD, Coryell W, Endicott J, et al.
Psychosocial disability and work role function compared across the long-term course of bipolar I, bipolar II and unipolar major depressive disorders. J Affect Disord 2008;108:49-58.
Allen CK, Allen RE. Cognitive disabilities: Measuring the social consequences of mental disorders. J Clin Psychiatry 1987;48:185-90.
Ware JE Jr., Manning WG Jr., Duan N, Wells KB, Newhouse JP. Health status and the use of outpatient mental health services. Am Psychol 1984;39:1090-100.
Sanderson K, Andrews G. Prevalence and severity of mental health-related disability and relationship to diagnosis. Psychiatr Serv 2002;53:80-6.
Goodwin FK, Jamision K. Manic-Depressive Illness. New York: Oxford University Press; 1990.
Robb JC, Cooke RG, Devins GM, Young LT, Joffe RT. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatr Res 1997;31:509-17.
Robb JC, Cooke RG, Devins G, Young LT, Joffe RT. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatry Res 1997;31:509-17.
[Table 1], [Table 2], [Table 3], [Table 4]