Bipolar I disorder is a lifelong illness marked by episodic recurrences that can be associated with functional decline, cognitive impairment, and a negative effect on quality of life. Even if bipolar I patients achieve symptomatic remission, they may have difficulty returning to baseline functioning. Listen to your colleagues discuss 3 broad categories of functional impairment, review scales that can help to assess function, and share ways in which they help patients in their own practices.
KM: Hello and welcome. My name is Dr Kathleen McCoy, psychiatric mental health nurse practitioner. I am so pleased to be joined today by my colleague, Dr Kameg, to bring you this podcast on functional impairment in patients with bipolar I disorder. Dr Kameg, how are you?
BK: Hi, Dr McCoy, I’m well, thank you. I’m Dr Brayden Kameg, and I am also a psychiatric mental health nurse practitioner. Dr McCoy, I know that we both have patients in our practices with diagnoses of bipolar I disorder, and I think that today’s topic is one we should always keep at the front of our minds when caring for patients. Sometimes, clinicians can be focused on clinical symptoms and treatment effects and forget to see the patient as a whole person. This topic really speaks to this.
KM: Absolutely, Dr Kameg. As we know, bipolar I disorder is a mood disorder characterized by major depressive episodes and manic episodes.1 The prevalence rate of bipolar I disorder in the United States is estimated to be 1% in adults.2
BK: Interestingly, most patients with bipolar I disorder present with depressive symptoms.1 Unfortunately, that might contribute to misdiagnosis, especially as major depressive disorder, or MDD. Early and accurate diagnosis of bipolar disorder is important because it not only can help reduce the burden of illness but also helps to improve long-term outcomes.1 For any interested listeners, we have included links below to pieces on the NP Psych Navigator website that more thoroughly detail the diagnosis and misdiagnosis of bipolar I disorder. Today we will focus on functional impairment in patients with bipolar I disorder, including types of functioning, how providers can quantitatively assess functioning in patients, and the importance of treating the whole patient.
KM: One important concept we must define here is “functioning.” What is functioning? The concept of functioning is certainly complex. It is important to note that there is no consensus on how to define psychosocial functioning in patients with bipolar disorder.3 I consider it to involve multiple different domains, including the capacity to work, such as absenteeism and presenteeism, and the ability to live independently and to enjoy fulfilling relationships. Others may add even more to this list.4
BK: Right, bipolar I disorder is a lifelong illness marked by episodic recurrences. It can be associated with functional decline, cognitive impairment, and a negative effect on quality of life.3 Unfortunately, even when patients do achieve symptomatic remission, there can be a gap in returning to baseline functioning.5 Patients with bipolar disorder who have achieved clinical remission often still experience residual mood symptoms, social dysfunction, and cognitive impairment. This can lead to a significant percentage of these patients continuing to suffer from poor psychosocial functioning even in the setting of symptomatic improvement.
KM: That’s right, Dr Kameg. In fact, a study of 162 patients with bipolar disorder showed that while 98% of the study population achieved syndromal recovery within 2 years after the first lifetime hospitalization, only 43% of these patients achieved functional recovery.6 Recovery from manic or depressive symptoms may be successful, but many bipolar I patients are left struggling with functional impairments. Another study shows that among some sets of patients with bipolar I disorder, nearly 100% exhibited persistent impairment in at least 1 area of functioning.7 Areas of functioning explored in this study included interpersonal relationships and recreational enjoyment.
BK: These statistics really drive home how devastating this condition can be for patients even outside of manic and depressive symptoms. As you said, only about one-third of patients experiencing the very first manic episode return to baseline psychosocial functioning in the following 2 years.3 Clinical factors that have been shown to correlate with functional impairment in patients with bipolar disorder include depressive symptoms, a history of psychosis, poor sleep quality, episode density, and a longer duration of illness.3 It is important as clinicians to note patients in whom these factors are present, and we may consider noting these items in the patient record.
KM: I like that you mention recording those important factors, Dr Kameg. Our understanding of effective management of bipolar disorder is now evolving to recognize that treatment of patients with bipolar I disorder must focus not only on clinical remission but also functional recovery.8 Today we will speak to the broad categories of functional impairment in patients with bipolar I disorder, the impacts these impairments can have on patient lives, and how we as clinicians can help improve patient functional recovery.
BK: Areas of functioning impacted in patients with bipolar I disorder can be thought of in categories. We will discuss 3 broad categories of patient functioning that are often impacted by this disorder, including: social functioning, occupational functioning, and family functioning. We will also discuss some tools that are used to assess functioning. Dr McCoy, what are some challenges these patients may have in the realm of social functioning?
KM: Patients with bipolar disorder tend to experience higher than usual levels of anxiety symptoms in social encounters, which may be influenced by low self-esteem and self-stigmatization.5 Social functioning in patients with bipolar disorder may also be impacted by an impairment in recognizing and/or decoding other people’s facial expressions. Even in patients experiencing clinical remission, limitations in facial emotional identification can have a negative impact on participation and inclusion in social activities and hobbies.5
BK: It’s easy to see how that could be very difficult for a patient, Dr McCoy. The next category, occupational functioning, refers to the capacity to maintain a paid job, efficiency of performing work duties, and working in the field in which the patient was educated or trained.4 Patients with bipolar I disorder can have difficulties with functioning in the workplace and in finding and maintaining employment. One study found that patients with bipolar disorder had a significantly higher unemployment rate when compared to populations without mental health problems. According to the study authors, this may have been influenced by lower psychosocial functioning that could negatively impact capacity to work and communication abilities. The authors found that executive functioning in these patients, which allows planning, focusing, and managing tasks, was positively correlated with occupational functioning, which means that impairments in executive functioning can affect the occupational functioning of patients with bipolar disorder.8
KM: One can imagine how deeply this can affect a person, from missed employment opportunities, to a loss of sense of purpose, to the reality of living without an adequate income. Another area affected for many patients with bipolar I disorder is family functioning. Patients with bipolar I disorder may struggle to maintain family relationships.9 In fact, challenges in family relationships are one of the most significant difficulties in patients living with bipolar disorder. In addition, poor family dynamics can be associated with increased overall functional impairment.9
BK: That’s right, Dr McCoy. Patients with bipolar I disorder, and their family members, have demonstrated a lack of family cohesion and adaptability, and a lack of family interpersonal relationships.9 These factors can result in a lower perceived family and social support system and are associated with challenges in establishing intimate relationships. Importantly, lower family cohesion and higher family conflict may predict worsening mood symptoms in patients with bipolar disorder.9 This underscores the importance of treating the whole patient, not only manic or depressive symptoms.
KM: So, what we really see here, Dr Kameg, is that in the realm of family functioning in particular, that impairment can be very interrelated with worsening mood symptoms. Now that we’ve reviewed some important areas in functional impairment that patients with bipolar I disorder may experience, let’s discuss how we identify and quantify functional impairment. How do you assess functioning in patients with bipolar I disorder, Dr Kameg?
BK: Dr McCoy, when assessing functioning in patients with bipolar I disorder, there are several clinical scales that can be used. These include the Global Assessment of Functioning scale, or GAF, which is the most commonly used,4 although it is not a tool specific to measuring functioning. Rather, it rates both symptoms and functioning. Other scales that measure functioning include the Social Adjustment Scale, or SAS, the Life Functioning Questionnaire, or LFQ, and the World Health Organization Disability Assessment Schedule, or the WHO-DAS. It is important to note that none of these were developed to assess specific areas of functional impairment in bipolar I disorder and they require a longer time for administration. For these reasons, I tend to use the FAST.4
KM: Dr Kameg, I also use the FAST, or the Functioning Assessment Short Test. The FAST is a brief questionnaire that can be used to assess the main functioning problems experienced by psychiatric patients in general and patients with bipolar disorder in particular.4 The FAST is made up of 24 items that assess impairment or disability in 6 specific areas of functioning. These areas are autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time or hobbies.4 The FAST assesses how much difficulty a patient has with various daily living tasks and occupational responsibilities, including those related to household management, independent living, shopping, personal hygiene, and job performance. It also helps assess elements of mental/intellectual and social functioning, including those related to concentration, reasoning and problem solving, memory, learning new tasks, and maintaining familial, social, and romantic relationships.4
The FAST is a clinician-rated scale that can be easily completed in the clinical setting, as it takes only about 6 minutes to administer. It can help clinicians to distinguish between euthymic and acutely symptomatic bipolar patients.4 The FAST, along with other useful scales that I use often in my own clinical practice, can be found in the Psychiatric Scale NPsychlopedia section of the NP Psych Navigator website. There is a link in the podcast notes for you to access below.
Of course, patient symptoms and history inform how often I reschedule for follow-up appointments, and I use the FAST at each of these visits. It is quick to complete and score, and I prefer having the objective data to add to the subjective interview. A sustained FAST total score of less than or equal to 11 can be used as a definition of functional recovery.10
BK: Once functional impairments have been identified in patients with bipolar I disorder, what are some strategies you have used in your practice to help improve functioning for these patients, Dr McCoy?
KM: Fantastic question, Dr Kameg. As our understanding of effective management of bipolar disorder is evolving to recognize that treatment of patients with bipolar I disorder must also focus on clinical remission and functional recovery, we should all aim to consider both spheres of the overall management of these patients.8 For example, to improve family functioning, which we have identified as having significant importance in overall well-being, family-focused therapy to promote emotional stability can be considered. Family-focused therapy can also improve problem-solving and communication skills for patients with bipolar disorder.9
BK: As we have discussed today, high rates of functional impairment among patients with bipolar disorder, even among patients whose symptoms have remitted, have been documented in multiple studies.4 Patients with bipolar I disorder often are impacted in multiple areas of their lives, including relationships with others and the ability to function at work and school. This can lead to an overall reduction in quality of life. Using clinical tools like the FAST can help providers and patients to identify specific functional impairments. The overall management goal for patients with bipolar I disorder should be improving not only bipolar symptoms, but also the level of functioning and quality of life of the patient with bipolar disorder.
KM: Absolutely. Dr Kameg, thank you so much for joining me today for this important discussion. We hope this has been helpful to you in your understanding of some challenges that patients with bipolar I may experience, and how we can continue to evolve in our management of this complex disorder.
BK: Thanks for joining us on NP Psych Navigator!
Kathleen McCoy, DNSc, APRN, PMHNP-BC, PMHCNS-BC, FNP-BC, FAANP
Dr Kathleen McCoy is an associate professor in the Department of Community and Mental Health at the University of South Alabama. She also works as a nurse practitioner for Integrated Telehealth Partners, where she provides psychiatric mental health care to patients. Dr McCoy earned her Master’s degree in Psychiatric Nursing from the State University of New York at Stony Brook and her Doctor of Nursing Science from the University of Tennessee Health Science Center.
Brayden Kameg, DNP, PMHNP-BC, CARN-AP, CNE
Dr Brayden Kameg currently serves as an assistant professor of nursing at the University of Pittsburgh in the Department of Health and Community Systems, where she coordinates the psychiatric-mental health nurse practitioner (PMHNP) program. Clinically, Dr Kameg is co-founder and co-owner of a private practice, Peace of Mind Psychiatry, where she treats patients across the lifespan. She is the founding program director of a PMHNP residency program at the Veterans Administration Pittsburgh Healthcare System, where she sees patients on an inpatient basis and in the addiction psychiatry program. Dr Kameg earned her BSN from the University of Pittsburgh in 2016 and her DNP in 2019.
Culpepper L. The diagnosis and treatment of bipolar disorder: decision-making in primary care. Prim Care Companion CNS Disord. 2014;16(3):PCC.13r01609. doi:10.4088/PCC.13r01609
- Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen H-U. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21(3):169-184. doi:10.1002/mpr.1359
- Bonnín CDM, Reinares M, Martínez-Arán A, et al. Improving functioning, quality of life, and well-being in patients with bipolar disorder. Int J Neuropsychopharmacol. 2019;22(8):467-477. doi:10.1093/ijnp/pyz018
- Rosa AR, Sánchez-Moreno J, Martínez-Aran A, et al. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin Pract Epidemiol Ment Health. 2007;3:5. doi:10.1186/1745-0179-3-5
- Aydemir O. Functioning and quality of life in bipolar disorder. Dusunen Adam J Psychiatry Neurol Sci. 2016;29:1-7. doi:10.5350/DAJPN20162901001
- Tohen M, Zarate CA Jr, Hennen J, et al. The McLean-Harvard first-episode mania study: prediction of recovery and first recurrence. Am J Psychiatry. 2003;160(12):2099-2107. doi:10.1176/appi.ajp.160.12.2099
- Strakowski SM, Williams JR, Fleck DE, Delbello MP. Eight-month functional outcome from mania following a first psychiatric hospitalization. J Psychiatr Res. 2000;34(3):193-200. doi:10.1016/s0022-3956(00)00015-7
- Ba Z, Chen M, Lai J, et al. Heterogeneity of psychosocial functioning in patients with bipolar disorder: associations with sociodemographic, clinical, neurocognitive and biochemical variables. Front Psychiatry. 2022;13:900757. doi:10.3389/fpsyt.2022.900757
- Dou W, Yu X, Fang H, et al. Family and psychosocial functioning in bipolar disorder: the mediating effects of social support, resilience and suicidal ideation. Front Psychol. 2022;12:807546. doi:10.3389/fpsyg.2021.807546
- Bonnín CM, Martínez-Arán A, Reinares M, et al. Thresholds for severity, remission and recovery using the functioning assessment short test (FAST) in bipolar disorder. J Affect Disord. 2018;240:57-62. doi:10.1016/j.jad.2018.07.045
This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.
NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributors are paid consultants for AbbVie Medical Affairs and were compensated for their time.
This is not a diagnostic tool and is not intended to replace a clinical evaluation by a healthcare provider.
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