Bipolar Disorder and Quality of Life

1

• Section 2
• Bipolar Disorder and Quality of Life

2
Quality of Life Definition

• Individuals perception of their position in life
  in the context of culture and value systems in
  which they live in relation to their goals,
  expectations, standards, and concerns
• Broad ranging concept affected in a complex way
  by the persons health, psychological state,
  level of independence, social relationships, and
  their relationships to salient features of their
  environment

The World Health Organization Quality of Life
(WHOQOL) Instruments. Available at
http//www.who.int/evidence/assessment-instruments
/qol/ql1.htm. Accessed February 7, 2006.
3
Assessment of Health-related Quality of Life

• Provides insight into the subjective experience
  of a person without relying solely on the
  objective (ie, medical tests) measures of
  well-being
• Recognizing the patients own appraisal is
  important
• Assessments of subjective experience are useful
  in understanding a variability in individual
  responses to a specific illness or disease,
  beyond that provided by medical measures
• Assessments may be used by researchers,
  clinicians, administrators, and healthcare
  professionals to evaluate treatment and cost
  effectiveness

The World Health Organization Quality of Life
(WHOQOL) Instruments. Available at
http//www.who.int/evidence/assessment-instruments
/qol/ql1.htm. Accessed February 7, 2006.
4
Depression Constitutes a Majority of Symptomatic
Time Spent With Affective Symptoms
NIMH Collaborative Depression Study 146
patients followed every 6 months over 220 years
Euthymia
5.9
9.3
Depression
9.4
52.7
Dysthymia
13.5
8.9
Subsyndromal
Elevated
Cycling
25 present with manic symptoms
10 years correct dx
Correct treatment
Onset of Symptoms
75 present with depressive symptoms
Judd LL, et al. Arch Gen Psychiatry.
200259530-537.
5
Impact of Bipolar Disorder
6
Ten Leading Causes of Years Lost to Disability
Worldwide, Year 2000 Estimate Persons Aged 15
to 44
Neuropsychiatric conditions are
highlighted. World Health Organization. The World
Health Report 2001. Available at
http//www.who.int/whr/2001/en/whr01_en.pdf.
7
More Dysfunction From Depression Than Mania in
Outpatients Who Screened Positive for Bipolar on
the Mood Disorder Questionnaire
90
Depression
80
Mania
70
60
Days ()
50
40
30
20
10
0
Disruptive Symptomsa
Impairment in Workb
Impairment in Social Lifeb
Impairment in Family Lifeb
aWithin 12 months prior to survey bWithin 4
weeks prior to survey. Calabrese JR, et al. J
Clin Psychiatry. 2004651499-1504.
8
Stanley Foundation Bipolar NetworkLife Chart
Method
60

• Only 8.9 had no episodes
• 2/3 substantially impacted by illness
• Just over 1/4 were ill for over 3/4 of a year

52.6
50
40
33.2
of 1 Year
30
20
10.8
10
3.4
0
Post RM, et al. J Clin Psychiatry.
200364680-690.
9
Psychosocial ImpairmentUnmet Needs
Marked or extreme over past 4 weeks Hirschfeld
RM. Eur Neuropsychopharmacol. 200414(suppl
2)S83-S88.
10
Psychosocial Impairment
Percent With Disruption
P lt 0.001
P lt 0.0001
P lt 0.0001
Greater functional impairment
Marked or extreme over past 4 weeks Hirschfeld
RM. Eur Neuropsychopharmacol. 200414(suppl
2)S83-S88.
11
ComorbiditiesThe Rule Not the ExceptionThe
Multidimensionality of Bipolar Disorder
DiabetesMellitus
Cardio-vascular
PainDisorders
Obesity
Migraine
BipolarDisorder
Substance Abuse
PersonalityDisorders
Comorbidities Medical Psychiatric
EatingDisorders
ADHD
AnxietyDisorders
ImpulseControl
McIntyre RS, et al. Human Psychopharmacol. 200419
369-386.
12
Medical Comorbidity in Bipolar DisorderA
Population-based Survey
No Bipolar
Bipolar
Diabetes 5.8 6.6 Cancer 2.0 2.3 Heart
disease 4.8 8.3 Effects of stroke 0.8 0.6 High
blood pressure 17.8 16.8 Migraine 11.6 20.3 Asthm
a 7.1 14.7
N 37,984
Significantly higher than estimate for people
without bipolar (P lt .05) McIntyre RS, et al.
Psychiatr Serv. In press.
13
Anxiety Disorder Comorbidityin Bipolar Disorder
McIntyre RS, et al. Bipolar Disord. 2006In press.
14
Functional Recovery

• Strong influence on occupational status
• 3060 do not regain full social or occupational
  functioning after onset of illness
• Lags behind symptomatic recovery and might not be
  complete even when mood symptoms have subsided

Bowden CL. Am J Managed Care. 200511S91-S94.
15
Character of the Initial Bipolar Episode
Influences the Correct Diagnosis
Lag Time Until Correct Diagnosis
14.4
N 56
11.6
Years Until Correct Diagnosis
6.6
4.7
Non- Psychotic
Psychotic
Non- Disabling
Disabling
Goldberg JF, Ernst CL. J Clin Psychiatry.
200263985-991.
16
Age at Onset

• STEP-BD, N 983, early onset predicts
• More lifetime manias and depressions
• More episodes past year
• More likely to present depressed or mixed
• Similar frequency of psychosis
• More comorbid conditions
• Increased suicide attempts (onset lt 13, OR 2.85)
• Lower QOL, but not functioning

Perlis RH, et al. Biol Psychiatry.
200455875-881.
17
Onset Age in Bipolar Disorder NDMDA Survey
30
28
25
20
16
15
14
of Members
15
12
9
10
5
5
0
lt 5
5-9
10-14
15-19
20-24
25-29
gt 29
Age (years)
Initial illness manifestations in childhood or
adolescent onset were associated with positive
family history, depressive or mixed initial
symptoms, and frequent recurrence with
predominantly depressive symptoms.
Lish JD, et al. J Affect Disord. 199431281-294.
18
Features Indicative of Bipolar Disorder
Unipolar
Bipolar
Moderate
Very High
Substance Abuse
Sometimes
Almost Uniform
Family History
Sometimes
Very Common
First Episode lt 25 yrs
Sometimes
Very Common
Postpartum Illness
Uncommon
Highly Predictive
Psychotic Features lt 35 yrs
Occasional
Common
Atypical Features
Unusual
Typical
Rapid On/Off Pattern
Unusual
Common
Recurrent MDE (gt 3)
Uncommon
Suggestive
Brief MDE (avg lt 3 months)
MDE major depressive episode Kaye NS. J Am
Board Fam Pract. 200518271-281.
19
Prevalence of Comorbidity of BPD and Other Axis
I Disorders
ADHD Attention Deficit Hyperactivity
Disorder OCD Obsessive Compulsive
Disorder Hilty DM, et al. Psychiatr Serv.
199950201-213.
20
National Comorbidity Survey

• 12 Month Prevalence (Kessler, 2005)
• Lay interviewers, AUDADIS (DSM-IV)
• N 14,093 over 18 years of age, representative
  households
• Any disorder 26.2
• 2 or more disorders (11.8)
• Major Depression 6.7
• Bipolar I and II 2.6
• Serious (82.9 )

Kessler RC, et al. Arch Gen Psychiatry.
200562617-627.
21
Primary or Secondary Substance Use

• STEP-BD, N 917, early onset predicts outcome
• 47.7 lifetime SUD
• 33.5 dependence, 14.2 abuse
• 42.8 alcohol, 12.8 other, 44.4 both
• 62.4 bipolar primary, 10.9 coincident
• Primary SUD associated with better course
• Early onset of bipolar has more deleterious
  effects

SUD Substance Use Disorder Fossey MD, et al. Am
J Addict. 200615138-143.
22
Effects of Co-occurring Alcohol on Bipolar
Disorder

• Naturalistic follow up for 5 years of type 1
  bipolar patients with first hospitalization, N
  144
• Alcohol First 19 Bipolar First 24 Bipolar
  Alone 57
• Alcohol First group was older, more likely to
  recover and recovered quicker
• Bipolar First group had more affective symptoms
  and more alcohol abuse than Alcohol First group
• Less mixed states in the Alcohol First group and
  mixed states correlated with alcohol use only in
  Bipolar First group
• High rates of subsequent alcohol lapses100
  Bipolar First, 78 Alcohol First

Strakowski SM, et al. Arch Gen Psychiatry.
200562851-858.
23
Lifetime Prevalence of Substance Use Disorders in
Mental Illnesses
9
70
8
61
60
7
48
47
50
6
36
5
40
33
Percent
31
Odds Ratio
27
4
30
3
20
2
10
1
0
0
Major Depression
OCD
Panic
Bipolar I
Bipolar II
Dysthymia
Schizophrenia
Regier DA, et al. JAMA. 19902642511-2518.
24
Differing Paths to Suicidal Ideas
BP I and II N 477, 20.5 Current SI
No Prior Lifetime AttemptN 296, 13 Current SI
Positive Lifetime Attempt N 181, 33 Current SI
Depression (4) Psychosocial Dysfunction
(31) Openness Anxiety (protects)
Extraversion (protects) 55 variance
Depression (31) Anxiety (promotes)
Neuroticism 59 variance

Allen MH, et al. Suicide Life Threat Behav.
200535671-680.
25
Increased Risk for Suicide Attempts With Delayed
Mood Stabilizer Initiation
12.2
Years of Delay to Mood Stabilizer
4.8
OR 7.3 (95 CI 1.632.6 P .01)
Goldberg JF, Ernst CL. J Clin Psychiatry.
200263985-991.
26
Prevalence of Bipolar I and II Among Survey
Respondents With Suicide-Related Behavior

• 12 months, NCS and NCS-R

NCS 1990-1992 National Comorbidity Survey NCS-R
2001-2003 National Comorbidity Survey
Replication Kessler RC, et al. JAMA.
20052932487-2495.
27
Factors Associated With SuicideAttempts in
Bipolar Illness
Course of Illness
Increased Cycling Severity of Depression
Comorbidities
Suicide Attempts
Genetic
Suicidal (D) and (M), Severity of Mania, More
time III (Prosp.), Early Onset
Axis I Anxiety and Eating Disorders,
Comorbidities, Axis II A, B, C
Family HX Depression, Bipolar, Alcohol, Other
Psych. Illnesses
Drug Abuse, Alcohol Abuse, PTSD
Suicide and Drug Abuse
Problems with Health Ins., and Access to Health
Care
Death of Imp. Other, Lack of Confidence
Occupational, Financial and Health Care
Adversities
Social
Occupational, Financial, Legal and Housing
Problems
Loss of Social Support, Social Role Demands,
Problems with Spouse (most recent episode)
Post RM, et al. Bipolar Disord. 20035310-319.
28
Treatment Aspects and Adherence for Bipolar
Disorder
29
TreatmentAspectsforBipolarDisorder
Need for Treatment
Acute Phase Treatment
Preventive / Maintenance
Substance use
Life Style
Full Concordance
Diagnosis
Psychosocial Intervention
30
Concordance and Adherence in Treatment Compliance

• Concordance the extent to which a patient and
  professional care provider agree as to the most
  appropriate treatment plan
• Adherence the extent to which the patient and
  provider follow the agreed upon plan
• Adherence with a treatment can be misleading
• If the plan is suboptimal
• If the assessment only considers use of
  medications

Spanarello S, et al. Encephale.
200531692-697 Lindenmayer JP, Khan A. Expert
Rev Neurother. 20044705-723. Wahl C, et al.
Heathc Q. 2005865-70
31
Concordance and Adherence in Treatment
Compliance (cont)
Patient and Clinicians view of most appropriate
treatment plan
Spanarello S, et al. Encephale. 200531692-697
Lindenmayer JP, Khan A. Expert Rev Neurother.
20044705-723 Wahl C, et al. Heathc Q.
2005865-70.
32
Individual Factors
33
Enhancement of Adherence and Improving Illness
Outcome in BPD

• While psychotherapy for bipolar disorder is known
  to generally improve illness outcome, it has been
  reported that interventions that focus on
  treatment adherence may yield positive results in
  this specific area

Cochran SD. J Consult Psychol. 198452873-878. Co
lom F. Bipolar Disord. 20024(suppl 1)102.
34
Interventions

• Educational
• Theory Verbal or written material, with a
  knowledge-based emphasis designed to convey
  information
• Example One-to-one and group teaching and use of
  written and audiovisual materials
• Behavioral
• Theory Designed to change adherence by
  targeting, shaping, or reinforcing specific
  behavioral patterns
• Example Skill building and practice activities,
  behavioral modeling and contracting, packaging
  and dosage modifications or tailoring, and
  reminders
• Affective
• Theory Appeals to feelings and emotions or
  social relationships and social supports
• Example Family support, counseling, and
  supportive home

Greater success is achieved when multiple
intervention approaches are used
Roter DL, et al. Med Care. 1998361138-1161.
35
Bipolar Disorder Coordinated Care Model
Care Manager Coordinates treatment Self-management
support Telephone management
Psychiatric Patient
GM Provider Decision Support Customized care
Psychiatrist Decision Support Referral
Kilbourne AM. Curr Psychiatry Rep. 2005710-17.
36
Quality of Care Bipolar Disorder

• Despite guidelines, quality of care for bipolar
  disorder suboptimal
• Drug toxicity monitoring
• Continuity of care
• Poor quality of care for co-occurring conditions
• Medical comorbidity
• Psychiatric comorbidity
• Validated, feasible, meaningful indicators
  represent the first steps towards improving care
  (cant improve what you cant measure)

Kilbourne AM, et al. Bipolar Disord.
20046368-373.
37
Dissatisfaction With Medical Care
(n 7187)
P lt .05 P lt .001
Kilbourne AM, et al. Paper presented at HSRD
National Meeting February 16-17, 2006
Arlington, Virginia.
38
Measuring Quality From a Systems Viewpoint NAMI
Grading the States 2006

• Comprehensive review, state by state
• Service provision and integration measures
• Focus also on functional outcome
• Overall... not a pretty picture
• Wide variation between performances in these
  measures
• Wide variation across states

National Alliance on Mental Illness.
State-by-state analysis of mental healthcare
systems in 15 years. Available at
http//www.nami.org/gtsTemplate.cfm?sectionGradin
g_the_stateslstid676. Accessed March 13, 2006.
39
Implications and Future Directions

• Suboptimal quality of care for all patients with
  bipolar disorder
• Improving quality requires
• Commitment to measuring quality using measures
  appropriate for older patients
• Co-occurring conditions (general medical,
  substance use)
• Strategies that target multilevel barriers
• Next generation identifying and reducing
  practice, plan, and population barriers to inform
  interventions

40
Summary

• BD causes significant and long-lasting distress,
  functional impairment, morbidity, and is
  associated with a high risk of mortality
• Quality of life and disease burden, particularly
  in terms of lifestyle and general functioning,
  are gaining increasing recognition as valid
  therapeutic targets for intervention
• Quality of life among patients with BD is
  significantly impaired both during and between
  acute episodes
• Somatic and mood symptoms, stigmatization,
  comorbid conditions, associated cognitive
  deficits and the burden of treatment all severely
  undermine patient quality of life