Return to Daily Functioning Elusive in Bipolar Disorder

Functional recovery—the ability to return to work and live independently—eludes the majority of patients with bipolar disorder, even years after being hospitalized for their first episode of mania, a new study finds. Furthermore, almost a third of patients remain symptomatic for years following discharge.

The results of the McLean-Harvard First-Episode Mania Study: Prediction of Recovery and First Recurrence appeared in the December 2003 American Journal of Psychiatry.

Principal investigator Mauricio Tohen, M.D., M.P.H., and colleagues recruited 166 patients admitted to McLean Hospital in Belmont, Mass., between 1989 and 1996. All had been hospitalized for the first time for either a manic or mixed episode.

Tohen is an associate clinical professor of psychiatry at Harvard Medical School and McLean Hospital and a clinical research fellow for Eli Lilly and Company.

He and his colleagues relied on reports from patients, relatives, treating clinicians, and scores from a variety of rating scales to track the patients’ outcomes two years after discharge.

Specifically, they examined three types of recovery: syndromal recovery (patients no longer met DSM-IV criteria for mania); symptomatic recovery (patients scored 5 or less on the Young Mania Rating Scale or 8 or less on the Hamilton Depression Rating Scale); and functional recovery (patients regained their premorbid occupational and residential status as measured by the Modified Vocational Status Index and the Modified Location Code Index).

The majority of patients in the sample (152) received at least one psychiatric medication upon discharge from McLean. However, at the two-year evaluation, 36 percent of the patients were not taking a medication.

The researchers found that by the two-year follow-up assessment, nearly all 166 patients had achieved syndromal recovery (98 percent). In the 92 patients for whom outcomes were available regarding symptoms, 71 percent achieved symptomatic recovery by the two-year mark.

Just 43 percent of the 137 patients for whom data were available on residential and occupational status achieved functional recovery at the two-year mark, a finding Tohen described to Psychiatric News as “troubling.”

“When you look at functional outcomes—the patient’s ability to return to work or live independently—the outlook isn’t good at all,” he said.

Even for those who achieved some form of recovery, it didn’t always last.

Within two years of having achieved syndromal recovery, 40 percent of the 62 patients experienced a new episode—31 patients had a new episode of mania, and the same number experienced a new episode of depression.

In addition, within two years, 32 of the 166 patients switched from an initial manic episode into depression, a mixed state, or psychosis, without first recovering.

The disparity between the number of subjects who achieved syndromal recovery and those who achieved functional recovery, according to the authors, wasn’t completely unexpected.

Tohen said many patients with bipolar disorder, even though not meeting DSM-IV criteria for an episode after treatment, still experience mild depressive symptoms over prolonged periods of time that may prevent them from being able to hold a steady job or return to a stable living situation.

In addition to developing treatments that address the subsyndromal symptoms of bipolar disorder, Tohen said, “We need to focus on improving outcomes related to functioning, which ultimately matter the most.”

Treatments should be administered early in the course of the illness and would ideally include a combination of pharmacotherapy and psychotherapy or psychosocial rehabilitation, he added.

The study was funded by grants from the National Institute of Mental Health, the Bruce J. Anderson Foundation, and the McLean Private Donors Neuropsychopharmacology Research Fund, and awards from Lilly Research Laboratories and the Atlas Foundation.

“The McLean-Harvard First-Episode Mania Study: Prediction of Recovery and First Recurrence” is posted online at http://ajp.psychiatryonline.org/cgi/content/full/160/12/2099?. ▪

Am J Psychiatry 2003 160 2099