In bipolar patients both manic and depressive episodes take their toll, of
course, but a large new population-based study finds that the depressive
phases are far more disabling on several key dimensions than are the manic
Among bipolar illness patients, depressive symptoms caused more serious
disruptions in occupational, family, and social functioning—findings,
researchers emphasized, that point to a need for strategies that will lead to
enhanced recognition and treatment of bipolar disorder.
The findings come from a study by Joseph Calabrese, M.D., of Case Western
Reserve School of Medicine; Robert Hirschfeld, M.D., of the University of
Texas Medical Branch at Galveston; Mark Frye, M.D., of UCLA; and Michael Reed,
Ph.D., of Vedanta Research in Chapel Hill, N.C., published in the November
2004 Journal of Clinical Psychiatry.
The health information used for the analysis came from questionnaires
completed in 2002 by 3,191 respondents out of a sample of 4,810, a 66 percent
return rate. The survey instruments were the Sheehan Disability Scale (SDS),
the Social Adjustment Scale Self-Report, the Mood Disorder Questionnaire
(MDQ), and a list of other questions.
The study population was drawn from a much larger sample of Americans aged
18 and older who were representative of the U.S. population in terms of age,
gender, geographic region, household size, and household income. In 2001 this
sample was sent and had completed the MDQ, a self-report, bipolar screening
instrument that has been validated in psychiatric outpatient settings and in
samples of the general U.S. population, the researchers noted.
For the follow-up study in 2002 the researchers chose a demographically
balanced sample that had screened positive for bipolar disorder based on the
2001 MDQ findings. This sample was then stratified by MDQ score and sent a
survey that questioned them on "symptom frequency and symptom
disruptiveness, consultation patterns, and occupational and psychosocial
impacts of symptoms."FIG1
The question eliciting symptom frequency and disruptiveness asked,"
How many days during the past four weeks did you experience
hyper/energetic feelings, and on how many days were they disruptive?"
Subjects were asked a similar question about "sad/down feelings."
Additional questions assessed these dimensions over the preceding 12-month
To determine consultation patterns, the researchers asked, in regard to
both of the mood states, whether subjects had "ever consulted a
physician or other health professional" and, if so, "what type of
physician or health care professional."
To assess the impact of bipolar symptoms on occupational and psychosocial
functioning, the researchers had subjects complete the SDS and the Social
Adjustment Scale Self-Report. The former describes symptom-related disruption
of usual activities relating to work, social, life, and family
responsibilities. The latter assesses the "ability to adapt to and
derive satisfaction from social roles" and includes questions on work
interest and performance, personal relationships, and ability to complete
household chores, for example.
The data from these instruments pointed to a considerably greater
disruption of work, social, and family life attributable to depressive than to
manic symptoms in bipolar patients. On the SDS instrument, for example, the
researchers found that 49 percent of subjects attributed "moderate or
greater impairment" of work activities to their depressive symptoms, 60
percent said depressive symptoms were more disruptive of social life, and 64
percent made this attribution for family life. When they looked at the
12-month data, the researchers identified the same pattern. When they took a
closer look at the work dimensions, they found that on a range of factors such
as "did work poorly," "having arguments," and"
feeling disinterest in work," subjects attributed significantly
more of their impairment to depressive than to manic symptoms.
Depressive symptoms were also more often the motivator for someone with
bipolar illness to see a physician or health care professional, the
researchers pointed out. Of those who sought professional help for their
symptoms, primary care clinicians were the most frequent choice, with 32
percent of subjects saying they most often consulted a primary care physician
for depressive symptoms; 21 percent of respondents most often consulted a
primary care physician for manic symptoms. Psychiatrists and psychologists
were consulted with about equal frequency by these respondents.
Calabrese and his colleagues said that their findings in this
community-based study—along with those from clinic-based
studies—are of particular concern because of recent research showing"
that length of time spent depressed predicts long-term outcome in
"These findings underscore the importance of effective prevention and
treatment of depressive episodes" in people with bipolar disorder, they
stated, and "suggest the historic focus, in research and in the
clinic," on treating mania in bipolar patients at the expense of
depressive episodes, which cause more impairment than manic ones, "may
"We have numerous medications available for the treatment of
mania," Calabrese told Psychiatric News, "but very few
available for the short- and long-term treatment of bipolar depression. I
believe the evidence would suggest that the greatest unmet medical need in
bipolar disorder is the clinical management of the depressed phase of the
Among the study limitations they noted were that "patient-friendly
terms" were used to determine the extent of impairment, and responses
were not verified in clinical interviews, which is the "gold standard
for valid diagnoses within psychiatry." Also, because of the study's
four-week and 12-month retrospective timeframes, "results may be subject
to recall bias, particularly for the data collected for the one year prior to
the survey," they said.
An abstract of the study, "Impact of Depressive Symptoms
Compared With Manic Symptoms in Bipolar Disorder: Results of a U.S.
Community-Based Sample," is posted online at<www.psychiatrist.com/abstracts/200411/110407.htm>.▪