 |
 |
|
|
|
Bipolar disorder (BD) is estimated to affect between 0.3% and 1.5% of individuals worldwide (1). Bipolar spectrum disorders have been less extensively studied but are likely to be more prevalent, affecting up to 8% of the population (2). Patient outcome in BD has traditionally been determined by the assessment of objective clinical information such as relapse rates, hospitalization, or degree of symptom reduction. However, increasing numbers of studies are now concomitantly examining symptomatic response and patient-centred assessment of broader domains of functioning. One specific area of research has focused upon patients’ perceptions of their quality of life (QoL) (3). QoL is a broad concept, but essentially, it refers to an individual’s well-being in a spectrum of such life domains as occupational, emotional, social, and physical functioning. Although a relatively large body of research has addressed the relation between QoL and unipolar major depressive disorder (MDD), there remains a paucity of data concerning QoL among patients with BD. There have been 2 reviews of the literature on QoL in BD. The first reviewed all English-language articles that described some form of health-related QoL assessment in patients with BD, conducted prior to 1999 (4). It identified a small number of rather heterogeneous, poorly designed studies employing various generic and depression-specific instruments to assess QoL. We undertook a second review of all English-language articles that addressed QoL in BD patients up to and including the year 2004 (unpublished, Michalak and others, 2004). Although research in this field remains sparse, our review identified increasing numbers of QoL studies with good design (that is, having adequate sample sizes and appropriate measures). Further, pharmacologic trials in BD populations are increasingly using QoL measures to assess patient outcome (for example, 5–7). In general, extant research has indicated that QoL is markedly impaired in patients with BD, even when they are considered to be clinically euthymic (see 8,9). Although pharmacology forms the bedrock of BD treatment (10,11), there is a clear need for other treatment modalities that augment the effects of medication in this complex psychiatric condition. Over the last decade, we have seen an upsurge of interest in the role of psychological interventions as adjuncts to the pharmacologic treatment of BD. Most of this research has concentrated on examining the efficacy of psychotherapy (in various guises). Several multimodal psychotherapeutic interventions have been developed for BD, such as family-focused treatment (FFT) (12,13), interpersonal and social rhythm therapy (14), and cognitive-behavioural therapy (CBT) (15). All these treatment interventions encompass patient psychoeducation (PE) (16). More recent research has also begun to address the efficacy of PE as a stand-alone treatment for BD (17,18), and manual-based, standardized PE interventions have now been developed (19,20). Although there has been a surge of interest both in QoL research in BD and in the effects of PE interventions for the condition, relatively little research has examined these factors in conjunction. We are unaware of any studies that have specifically addressed the effects of PE interventions upon QoL. The primary objective of this study was to assess the impact of time-limited group PE upon perceived QoL in BD patients who were considered clinically euthymic. We formed no specific hypotheses concerning the domains of QoL that might be most affected by PE, because the intervention was designed to address several areas of well-being. Instead, we predicted that PE would have a significant positive impact upon overall QoL and aimed to use post hoc exploratory analyses to determine whether PE had a more pronounced impact on some domains than on others. We also predicted that patients who had experienced more episodes of depression would exhibit poorer QoL at baseline. MethodThis was a pragmatic, retrospective chart review of an 8-session, standardized group PE treatment program for patients with BD. Group PE was offered between 1996 and 2002 at the Mood Disorders Clinic, University of British Columbia Hospital, a tertiary teaching hospital located on a university campus in Vancouver, British Columbia. We obtained charts from hospital records for all patients who had participated in the clinical program and who had completed questionnaires at both baseline and 8 weeks. Participants Participants were 57 adults with a primary (clinical) diagnosis of BD I or II. They were required to be considered stabilized and either euthymic or mildly symptomatic. Most were referred to the group as outpatients by either their primary care physician or a community psychiatrist. All participants continued to be treated by their referring physician. Adjustments to medication were permitted during the course of the group PE. Patients were not eligible for the group if they were in an acute phase of their illness, were diagnosed with borderline or antisocial personality disorder, or had received a diagnosis of alcohol or other substance abuse in the previous 6 months. Because this study was based on data routinely collected as part of the clinical evaluation process, no informed consent was obtained. Group PE The group PE was delivered in eight 1.5-hour blocks, on a weekly basis, with group sizes varying between 6 and 20 participants. The sessions were led by a nurse, a social worker, and a psychiatrist and followed a structured format (see Table 1) similar in nature to other manual-based PE interventions for BD (19,20). The group PE objectives were as follows: 1. To help patients identify the signs and symptoms of depression and mania and to enhance knowledge about the course of illness and risk factors for relapse. 2. To raise awareness concerning the impact of BD on psychological, cognitive, physical, emotional, and social functioning. 3. To improve knowledge of the major pharmacologic treatment modalities for BD and their common side effects. 4. To provide guidelines for increased medication effectiveness and safety. 5. To heighten awareness of cognitive strategies for coping with BD. 6. To increase self-confidence, self-awareness, and social skills through interaction with other group members.
QoL Assessment Perceived QoL was assessed via the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) (21) at baseline (Week 1) and at the final group session (Week 8). The Q-LES-Q is a 93-item, self-report measure of the respondent’s degree of enjoyment and satisfaction in various areas of daily living. It was developed and validated for outpatients suffering from depression and has 8 summary scales derived from 91 items that reflect the major domains of physical health, mood, leisure time activities, social relationships, general activities, work (if applicable), household duties (if applicable), and school or coursework (if applicable). It takes between 10 and 25 minutes to complete, depending on the number of applicable domains. The raw summary scales of the questionnaire are summed to produce a mean QoL score ranging from 0 to 100; higher scores indicate better QoL. The questionnaire also possesses single items that rate “overall life satisfaction and contentment” and “satisfaction with medications (if any are taken).” Reported internal consistency (Cronbach’s alpha) for the Q-LES-Q domains ranges from 0.90 to 0.96; test–retest reliability ranges between 0.63 and 0.89 (21,22). Patients completed the questionnaire independently. Statistics Summary scores for the 8 Q-LES-Q domains were derived and transformed linearly to a scale ranging from 0 to 100. Using paired t tests, we compared pre- and postgroup mean Q-LES-Q scores (calculated for the questionnaire’s 8 domains and 2 additional items). We used stepwise multiple regression to explore the effect of demographic and clinical characteristics on mean pre- and postgroup Q-LES-Q scores. Independent variables entered into the analysis included sex, age, diagnosis (BD I or II), most recent episode (depressed, manic, or mixed), number of previous manic episodes, and number of previous depressed episodes. All calculations were undertaken with SPSS version 10.1 (23). ResultsQ-LES-Q Scores Table 2 provides diagnostic and demographic information for the patient population (n = 57) that was obtained from the patient’s psychiatrist on referral to the Mood Disorders Clinic and from reference to hospital records. Table 3 provides pre- and postgroup Q-LES-Q domain scores. Mean Q-LES-Q scores were significantly higher after the group PE, compared with pregroup scores (P = 0.02). Closer inspection of the questionnaire’s separate domain scores reveals that significant changes occurred in 2 of the 8 domains, (specifically, physical health and general satisfaction) and in the 2 single items assessing “overall life satisfaction and contentment” and “satisfaction with medications.”
Multivariate Analysis We conducted multiple regression analysis of the predictors of mean Q-LES-Q scores for 45 patients with complete data (10 cases were excluded from the analysis because they lacked demographic or historical information, and 2 cases were excluded because Q-LES-Q data were missing). This analysis determined that only one variable—having had a recent episode of depression—significantly predicted poorer pretreatment Q-LES-Q scores (R2adj = 8%, F1,45 = 5.2, P < 0.05). For posttreatment scores, a significant model emerged (R2adj = 28%, F1,44 = 9.9, P < 0.001): both having had a recent episode of depression (β = –0.40, P = 0.003) and having had more depressive episodes in the past (β = –0.35, P = 0.009) predicted poorer QoL. Further analysis of the data revealed that patients whose most recent episode had been one of depression had pregroup mean Q-LES-Q scores of 48, SD 14, compared with pregroup mean scores of 63, SD 11, in patients whose most recent episode had been one of mania (t48= 4.2, P < 0.001). DiscussionIn the present study, patients with BD who completed an 8-week group PE course had mean baseline Q-LES-Q scores of 56%. This score is somewhat higher than scores reported in previous studies using the Q-LES-Q with BD patients, which indicated moderate impairment in perceived QoL (that is, scores ranging from 30% to 50%). For example, a recent Turkish study using the Q-LES-Q in interepisode patients with BD (n = 100) reported mean scores of 37% (24). Using multivariate analysis, the authors further reported that no historical variables (including age at first episode, number of previous depressive or manic episodes, duration of illness, number of hospitalizations, age at first hospitalization, or number of symptoms during first episode) predicted mean Q-LES-Q scores, although current depression did significantly predict lower scores. These data are in keeping with our own, which indicate an association between recent depression and poorer baseline QoL. In another study, Ritsner and colleagues examined Q-LES-Q scores in a sample of Israeli patients (n = 199) with severe mental illness, 17 of whom were diagnosed with BD (25,26). These authors informed us that mean Q-LES-Q scores for the manic, depressed, and mixed subgroups of BD patients were 40%, 25%, and 33%, respectively (M Ritsner and colleagues, personal communication, 2003). Previous studies using the Q-LES-Q in other patient populations have reported mean baseline scores of 55% in patients with chronic MDD (27) and 56% in patients with posttraumatic stress disorder (28). Our study detected a 5-point change in mean Q-LES-Q scores following the group PE intervention. Few previous treatment studies using the Q-LES-Q as an outcome measure are readily comparable with the present study. The questionnaire has been used to assess outcome in the treatment of dysthymia with sertraline, imipramine, or placebo; after 12 weeks of treatment, an 8-point change was reported in the 2 active intervention arms and a 4-point change in the placebo arm (29). In a study of the treatment of chronic depression (that is, double depression or chronic MDD) with either sertraline or imipramine, a 9-point change was seen after 4 weeks of treatment and a 14-point change after 12 weeks (30). In comparison with these outcome studies, a 5-point change in mean Q-LES-Q score may constitute a modest treatment effect; the clinical significance of this degree of change is unclear. There are, of course, inherent problems in comparing treatment effects across diverse patient populations and therapeutic interventions. Our sample consisted of euthymic or mildly symptomatic patients (that is, patients showing no marked depressive, hypomanic, or manic symptomatology according to clinical opinion) who may have been less likely to exhibit large change scores. Moreover, it is difficult to ascertain the treatment effects of an intervention such as group PE from a retrospective chart review with no control group, which does constitute a significant limitation of this study. It could, alternatively, have been group affiliation that improved QoL rather than a specific effect of PE per se. It is also worth noting that the PE intervention did not uniformly improve all domains of QoL. Significant improvement was seen in mean Q-LES-Q scores, and there was a trend toward improved QoL in most of the questionnaire’s domains. However, only 2 of the 8 domains (specifically, physical functioning and general satisfaction, which is a composite of all the questionnaire’s domains) were significantly improved on an individual level. Thus group PE appeared to have a weak general effect on all aspects of QoL but a more pronounced specific effect on physical functioning. Two of the 8 PE sessions focused on treatment issues in BD, covering topics such as management of side effects, adherence, general health, activity schedules, and sleep hygiene. Education in these issues may have allowed group members to make relatively rapid changes in their lives to improve their physical functioning, whereas changes in work and social functioning may be slower to implement. That a gap may occur between symptomatic and functional recovery, with improvements in psychosocial functioning lagging behind physical improvements, has now been shown in several studies of populations with BD There are other methodological considerations specific to our study. First, we did not collect objective measures of depression severity for our patient population. It is possible that patients with more severe depression were less likely to complete the PE course, which may have inflated the treatment effect obtained. However, the fact that baseline Q-LES-Q scores (which contained measures of mood and functioning) did not differ significantly between completers and noncompleters does not support this notion. Second, we did not have any control over changes in the medications patients were receiving. It is possible that changes in dosage or type of medication could have had short-term effects upon QoL. These potential limitations are specific to the study design we used and are the product of performing a pragmatic retrospective study of a treatment intervention for BD, delivered in a naturalistic setting. However, there are several additional hurdles to overcome in QoL research generally, especially when it is conducted in populations with chronic mental disorders. Most measures of QoL rely on a subjective, not objective, assessment of well-being made when the ability of individuals to assess their own status can be affected by their mental illness (33). Depression is inextricably linked to problems of assessment, attribution, and evaluation, all of which may influence self-report measures of functioning and well-being. For example, individuals suffering from depression are more likely to inflate the severity of their social impairment (34). This has led some (35–37), but not all (38,39), to argue that the assessment of QoL should be based primarily on objective data. That the patients in our study were generally euthymic may have gone some way toward minimizing these potential confounding effects. Finally, an important step forward would be made in this field if a disease-specific measure of QoL for populations with BD were to be developed. In conclusion, we found that an 8-week, standardized group PE intervention was associated with improved perceived QoL in a group of clinically euthymic BD patients. Although preliminary and limited by the lack of controlled design, the study results add to a growing body of evidence concerning the benefits of adding psychosocial interventions to our armory of treatments for BD. A more comprehensive approach toward the management of BD—one that complements established pharmacotherapy interventions with psychological interventions—may take us one step further toward reducing the impact of this disabling disorder on patients’ functioning and life enjoyment. AcknowledgementsWe extend our thanks to Jeanette Eyre and Shazina Karim for their assistance in delivering the group PE. References1. Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, and others. Cross-national epidemiology of major depression and bipolar disorder. JAMA 1996;276:293–9. 2. Angst J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 1998;50:143–51. 3. Tsevat J, Weeks JC, Guadagnoli E, Tosteson AN, Mangione CM, Pliskin JS, and others. Using health-related quality-of-life information: clinical encounters, clinical trials, and health policy. J Gen Intern Med 1994;9:576–82. 4. Namjoshi MA, Buesching DP. A review of the health-related quality of life literature in bipolar disorder. Qual Life Res 2001;10:105–15. 5. Namjoshi MA, Rajamannar G, Jacobs T, Sanger TM, Risser R, Tohen MF, and others. Economic, clinical, and quality-of-life outcomes associated with olanzapine treatment in mania. results from a randomized controlled trial. J Affect Disord 2002;69:109–18. 6. Shi L, Namjoshi MA, Zhang F, Gandhi G, Edgell ET, Tohen M. Olanzapine versus haloperidol in the treatment of acute mania: clinical outcomes, health-related quality of life and work status. Int Clin Psychopharmacol 2002;17:227–37. 7. Namjoshi MA, Risser R, Shi L, Tohen M, Breier A. Quality of life assessment in patients with bipolar disorder treated with olanzapine added to lithium or valproic acid. J Affect Disord 2004;81:223–9. 8. Cooke RG, Robb JC, Young LT, Joffe RT. Well-being and functioning in patients with bipolar disorder assessed using the MOS 20-ITEM Short Form (SF-20). J Affect Disord 1996;39:93–7. 9. MacQueen GM, Young LT, Robb JC, Cooke RG, Joffe RT. Levels of functioning and well-being in recovered psychotic versus nonpsychotic mania. J Affect Disord 1997;46(1):69–72. 10. Suppes T, Dennehy EB, Swann AC, Bowden CL, Calabrese JR, Hirschfeld RM, and others. Report of the Texas Consensus Conference Panel on Medication Treatment of Bipolar Disorder 2000. J Clin Psychiatry 2002;63:288–99. 11. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002;159(4 Suppl):1–50. 12. Miklowitz DJ, Goldstein MJ, Nuechterlein KH, Snyder KS, Mintz J. Family factors and the course of bipolar affective disorder. Arch Gen Psychiatry 1988;45:225–31. 13. Miklowitz DJ, Goldstein MJ. Bipolar disorder: a family-focused treatment approach. New York: Guilford Press; 1997. 14. Frank E, Swartz HA, Kupfer DJ. Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder. Biol Psychiatry 2000;48:593–604. 15. Otto MW, Reilly-Harrington N, Sachs GS. Psychoeducational and cognitive-behavioral strategies in the management of bipolar disorder. J Affect Disord 2003;73:171–81. 16. Michalak EE, Yatham LN, Lam RW. The role of psychoeducation in the treatment of bipolar disorder: a clinical perspective. Clinical Approaches in Bipolar Disorders. 2004;3(1);5–11. 17. Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea JM, Benabarre A, and others. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003;60:402–7. 18. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ 1999;318:149–53. 19. Bauer M, McBride L. The Life Goals Program: structured group pschotherapy for bipolar disorder. New York: Springer Publishing Co; 1996. 20. Bauer MS, McBride L, Chase C, Sachs G, Shea N. Manual-based group psychotherapy for bipolar disorder: a feasibility study. J Clin Psychiatry 1998;59:449–55. 21. Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull 1993;29:321–6. 22. Bishop SL, Walling DP, Dott SG, Folkes CC, Bucy J. Refining quality of life: validating a multidimensional factor measure in the severe mentally ill. Qual Life Res 1999;8:151–60. 23. SPSS for Windows. Version 10.1.0. Chicago (IL): SPSS Inc; 2000. 24. Ozer S, Ulusahin A, Batur S, Kabakci E, Saka M. C. Outcome measures of interepisode bipolar patients in a Turkish sample. Soc Psychiatry Psychiatr Epidemiol 2002;37(1):31–7. 25. Ritsner M, Modai I, Endicott J, Rivkin O, Nechamkin Y, Barak P, and others. Differences in quality of life domains and psychopathologic and psychosocial factors in psychiatric patients. J Clin Psychiatry 2000;61:880–9. 26. Ritsner M, Kurs R, Kostizky H, Ponizovsky A, Modai I. Subjective quality of life in severely mentally ill patients: a comparison of two instruments. Qual Life Res 2002;11:553–61. 27. Russell JM, Koran LM, Rush J, Hirschfeld RM, Harrison W, Friedman ES, and others. Effect of concurrent anxiety on response to sertraline and imipramine in patients with chronic depression. Depress Anxiety 2001;13(1):18–27. 28. Rapaport MH, Endicott J, Clary CM. posttraumatic stress disorder and quality of life: results across 64 weeks of sertraline treatment. J Clin Psychiatry 2002;63(1):59–65. 29. Kocsis JH, Zisook S, Davidson J, Shelton R, YonkersK, Hellerstein DJ, and others. Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: psychosocial outcomes. Am J Psychiatry 1997;154:390–5. 30. Miller IW, Keitner GI, Schatzberg AF, Klein DN, Thase ME, Rush AJ, and others. The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine. J Clin Psychiatry 1998;59:608–19. 31. Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment in bipolar disorder. Am J Psychiatry 1995;152:1635–40. 32. Tohen M, Hennen J, Zarate CM Jr, Baldessarini RJ, Strakowski SM, Stoll AL, and others. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry 2000;157:220–8. 33. Atkinson M, Zibin S, Chuang H. Characterizing quality of life among patients with chronic mental illness: a critical examination of the self-report methodology. Am J Psychiatry 1997;154:99–105. 34. Morgado A, Raoux N, Jourdain G, Lecrubier Y, Widlocher D. Over-reporting of maladjustment by depressed subjects. Findings from retesting after recovery. Soc Psychiatry Psychiatr Epidemiol 1991;26(2):68–74. 35. Jenkins CD. Assessment of outcomes of health intervention. Soc Sci Med 1992;35:367–75. 36. Epstein AM, Hall JA, Tognetti J, Son LH, Conant L Jr. Using proxies to evaluate quality of life. can they provide valid information about patients’ health status and satisfaction with medical care? Med Care 1989;27(3 Suppl):S91–S98. 37. Rosenblatt A, Attkisson CC. Assessing outcomes for sufferers of severe mental disorder: a conceptutal framework and review. Evaluation and Program Planning 1993;16:347–63. 38. Leidy NK, Palmer C, Murray M, Robb J, Revicki DA. Health-related quality of life assessment in euthymic and depressed patients with bipolar disorder. psychometric performance of four self-report measures. J Affect Disord 1998;48:207–14. 39. Russo J, Roy-Byrne P, Reeder D, Alexander M, Dwyer-O’Connor E, Dagadakis C, and others. Longitudinal assessment of quality of life in acute psychiatric inpatients: reliability and validity. J Nerv Ment Dis 1997;185:166–75. Author(s)Manuscript received April 2003, revised, and accepted February 2004. 1. Research Associate, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. 2. Professor and Head, Division of Clinical Neuroscience, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. 3. Research Assistant, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. 4. Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. Address for correspondence: Dr EE Michalak, Division of Mood Disorders, Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1 e-mail: emichala@interchange.ubc.ca
1 | 2
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||