People with severe mental illness (SMI) experience high levels of unemployment. We aimed to better understand the associations between clinical, social, and demographic inequality indicators and unemployment.

Data were extracted from de-identified health records of people with SMI in contact with secondary mental health services in south London, UK. A Natural Language Processing text-mining application was applied to extract information on unemployment in the health records. Multivariable logistic regression was used to assess associations with unemployment, in people with SMI.

Records from 19,768 service users were used for analysis, 84.9% (n = 16,778) had experienced unemployment. In fully adjusted models, Black Caribbean and Black African service users were more likely to experience unemployment compared with White British service users (Black Caribbean: aOR 1.62, 95% CI 1.45-1.80; Black African: 1.32, 1.15-1.51). Although men were more likely to have experienced unemployment relative to women in unadjusted models (OR 1.36, 95% CI 1.26-1.47), differences were no longer apparent in the fully adjusted models (aOR 1.05, 95% CI 0.97-1.15). The presence of a non-affective (compared to affective) diagnosis (1.24, 1.13-1.35), comorbid substance use (2.02, 1.76-2.33), previous inpatient admissions (4.18, 3.71-4.70), longer inpatient stays (78 + days: 7.78, 6.34-9.54), and compulsory admissions (3.45, 3.04-3.92) were associated with unemployment, in fully adjusted models.

People with SMI experience high levels of unemployment, and we found that unemployment was associated with several clinical and social factors. Interventions to address low employment may need to also address these broader inequalities.

The goal of this study was to assess psychosocial functioning in older patients with bipolar I disorder compared with healthy subjects and to identify the psychopathological factors associated with poor functioning in patients.

We recruited 68 euthymic patients with bipolar I disorder from the outpatient unit and 89 healthy controls who were older than 50 years of age. In addition to clinical variables, we used other standardized measures, including the Young Mania Rating Scale, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Functional Assessment Short Test, and the Montreal Cognitive Assessment.

Older patients with bipolar I disorder had poorer psychosocial functioning in general and in the domains of occupation, autonomy, and cognition than the healthy controls on the basis of previously defined Functional Assessment Short Test cutoff scores. We found that 35.3% (95% CI: 23%-47%) of the patients did not have clinically significant functional impairment, 38.2% (95% CI: 26%-50%) had mild impairment, and 26.5% (95% CI: 16%-37%) had moderate impairment. Depressive symptoms and impaired cognition were associated with poor overall functioning.

The level of psychosocial functioning was heterogeneous among the patients. Subsyndromal depressive symptoms, even at low levels, and impaired cognition predicted poor functioning in euthymic middle-aged and older patients with bipolar I disorder.

Major Depressive Disorder and Bipolar Disorder are psychiatric disorders associated with psychosocial impairment. Despite clinical improvement, functional complaints usually remain, mainly impairing occupational and cognitive performance. The aim of this study was to use machine learning techniques to predict functional impairment in patients with mood disorders. For that, analyzes were performed using a population-based cohort study. Participants diagnosed with a mood disorder at baseline and reassessed were considered (n = 282). Random forest (RF) with previous recursive feature selection and LASSO algorithms were applied to a training set with imputed data by bagged trees resulting in two main models. Following recursive feature selection, 25 variables were retained. The RF model had the best performance compared to LASSO. The most important variables in predicting functional impairment were sexual abuse, severity of depressive, anxiety, and somatic symptoms, physical neglect, emotional abuse, and physical abuse. The model demonstrated acceptable performance to predict functional impairment. However, our sample is composed of young participants and the model may not generalize to older individuals with mood disorders. More studies are needed in this direction. The presented calculator has clinical, sociodemographic, and environmental data, demonstrating that it is possible to use such information to predict functional performance.

Bipolar disorder is a severe and chronic mental illness that could continue for a lifetime. Although it is a leading cause of disability and impairments for significant numbers of patients, the levels of functional outcomes have not been studied in Ethiopia. Therefore, this study aimed to assess the functional outcome levels and associated factors among bipolar disorder patients in Northwest Ethiopia.

Hospital-based cross-sectional study was employed among bipolar disorder patients attending psychiatric clinics, in Northwest Ethiopia, from April to June 2021. Systematic random sampling was used to get respondents. Descriptive and inferential statistics were done. Data were entered into EpiData version 4.6.02 and exported to SPSS Version 22 for analysis. Bivariable and multivariable binary logistic regression analysis was used to identify the factors associated with functional outcome levels, and p value < 0.05 was considered significant with 95% CI.

Of the total 423 study participants approached, only 411 completed the questionnaire, with a response rate of 97.2%. The median (IQR) level of functional outcome was 6 (0-22) and 40% of the study subjects were impaired. Leisure time was the most normal functioning domain (92.2%), whereas cognitive (43.5%) and occupational (41.6%) domains were the most impaired domains. Unemployment (AOR (95%CI) = 3.9 (1.46-10.49), obesity (AOR (95% CI) = 6.5 (1.22-34.58), depressed and manic mood phases (AOR (95%CI) = 5.2 (2.84-9.35) and (AOR (95%CI) = 7.8 (3.31-18.34) respectively, medication non-adherence (AOR (95% CI) = 3.2 (1.71-6.05), and relapsed once or ≥ twice (AOR (95%CI) = 2.2 (1.25-3.98) and (AOR (95%CI) = 8.3 (2.73-25.30), respectively, were some of the important predictor variables that were significantly associated to the functional impairments levels.

The median of functional outcomes levels was found in an acceptable range; however, significant numbers of bipolar patients were functionally impaired. Moreover, patients still need unrestricted interventions in the cognitive and occupational functional domains. Socio-demographic, clinical, medication, and psychosocial variables were significantly associated with functional outcomes. Bipolar patients need to be followed and managed to improve their functional outcome and all stakeholders should be involved to achieve the recommended levels.

The objective of the present study was to determine the problems and information needs of patients with bipolar disorder during the treatment process. The present research is in the type of descriptive and qualitative study. In-depth individual interviews were conducted with 11 volunteer patients with bipolar disorder. The data collected from the interviews were evaluated using the descriptive analysis method. In the study, four categories (disease onset/diagnosis stage, adherence to treatment, interpersonal relationships, information needs) and nine main themes (symptoms, family support, factors that positively affect treatment adherence, factors that negatively affect treatment adherence, positive effects of treatment, negative effects of treatment, stigmatization, treatment, disease) were determined. Patients with bipolar disorder can be helped to cope with the problems they experience by providing information about the disease, adherence to treatment, the treatment process, and the effects of drugs.

Functional status could predict development of bipolar disorder (BD) or have clinical significance. The relationship between BD risk and functioning is poorly understood. We undertook a systematic review examining the global and social functioning of those at risk for BD.

We examined observational studies comparing a risk sample with healthy controls or full-threshold BD participants, using measures of global or social functioning. Risk status included family history of BD, meeting risk criteria, or having prodromal symptomatology, or premorbid functioning of persons with BD. Medline, PsycINFO, and Embase were searched. The Newcastle-Ottawa Scale for Cross-Sectional Studies was used to assess quality. Meta-analyses were performed where possible.

7215 studies were screened and 40 studies were included (8474 participants). Risk samples had poorer functioning than controls, and superior functioning to participants with BD. Meta-analysis indicated poorer global functioning among persons with familial risk compared to healthy controls (mean global functional difference: 5.92; 95 % confidence interval: 7.90, 3.95; mean premorbid functioning difference: 2.31; 95 % confidence interval: 0.70, 3.92). Studies with higher proportions of female participants had slightly poorer global functioning. High heterogeneity was attributable functional measures and potentially functionally differential subgroups within the risk samples.

Broader measures of functioning, such as neurocognition and behavioural measures, were excluded. Measures of global functioning are limited by conflating functioning and symptoms.

Functioning in the BD risk populations is intermediate to that of healthy controls and persons with BD, indicating their value in definitions of BD risk, in itself a likely heterogeneous state.

Patients with bipolar disorder experience impairments in their occupational functioning, despite remission of symptoms. Previous research has shown that neurocognitive deficits, especially deficits in executive functions, may persist during euthymia and are associated with diminished occupational functioning.

The aim of this scoping review was to identify published studies that report on the relationships between executive functions and occupational functioning in BD to review current knowledge and identify knowledge gaps. In addition to traditional neuropsychological approaches, we aimed to describe executive functioning from a self-regulation perspective, including emotion regulation.

We applied the methodological framework as described by Arksey and O'Malley (Int J Soc Res Methodol Theory Pract 8:19-32, 2005) and Levac et al. (Implement Sci 5:1-9, 2010). We searched PubMed and psycINFO for literature up to November 2021, after which we screened papers based on inclusion criteria. Two reviewers independently performed the screening process, data charting process, and synthesis of results.

The search yielded 1202 references after deduplication, of which 222 remained after initial screening. The screening and inclusion process yielded 82 eligible papers in which relationships between executive functions and occupational functioning are examined.

Neurocognitive deficits, including in executive functions and self-regulation, are associated with and predictive of diminished occupational functioning. Definitions and measurements for neurocognitive functions and occupational functioning differ greatly between studies, which complicates comparisons. Studies on functional remediation show promising results for improving occupational functioning in patients with BD. In research and clinical practice more attention is needed towards the quality of work functioning and the various contexts in which patients with BD experience deficits.

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Due to current depression prevalence, it is crucial to make the correct diagnosis as soon as possible. The study aimed to identify commonly available, easy to apply, and quick to interpret tools allowing for a differential diagnosis between unipolar and bipolar disorder. The study group includes women with long duration of unipolar (UP, N = 34) and bipolar (BP, N = 43) affective disorder. The diagnosis was established according to the DSM criteria using SCID questionnaire. Additional questionnaires were used to differentiate between UP and BP. BP patients had an earlier age of onset, were hospitalized more times, and more often had a family history of psychiatric disorders than UP (p-value < 0.05). Moreover, BP achieved a higher impulsiveness score and more frequently had experienced severe problems with close individuals. To our knowledge, this is the first publication presenting results of numerous questionnaires applied simultaneously in patients on clinical group. Several of them suggest the direction of clinical assessment, such as: the age of onset, family psychiatric burdens, history of stressful life events, learning problems, social and job relations. Further studies are necessary to confirm the utility of this approach.

The identification of factors that prevent self-stigma and on the other hand promote stigma resistance are of importance in the long-term management of bipolar disorder. Accordingly, the aim of the current study was to investigate the association of factors deemed relevant in this context, i.e., resilience, premorbid functioning, and residual mood symptoms, with self-stigma/stigma resistance. Sixty patients diagnosed with bipolar I disorder were recruited from a specialized outpatient clinic. Self-stigma and stigma resistance were measured by the Internalized Stigma of Mental Illness (ISMI) Scale. The presence and severity of symptoms were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS). Resilience and premorbid functioning were measured by the Resilience Scale (RS-25) and the Premorbid Adjustment Scale (PAS), respectively. Resilience correlated negatively with self-stigma and positively with stigma resistance and was a predictor for self-stigma/stigma resistance in multiple linear regression analysis. Residual depressive symptoms correlated positively with self-stigma and negatively with stigma resistance. There were no significant correlations between sociodemographic variables, premorbid functioning as well as residual manic symptoms and self-stigma/stigma resistance. The findings of this study implicate that resilience may be considered as an important component of self-stigma reduction interventions.

Systematically review the prevalence of functional impairment (FI) in euthymic patients with bipolar disorder (BD), as assessed only with the Functioning Assessment Short Test (FAST), explore the prevalence of this impairment among all the domains, identify the most compromised of them and the clinical variables associated with low functioning in this population.

Meta-analyses were performed, searching for relevant papers published from 2007 to 2019 in Medline, Embase, Cochrane, PsycINFO databases and via hand-searching, without language restrictions. 1128 studies were initially identified, 13 of which were ultimately chosen based on the eligibility criteria. A two-step meta-analysis was performed using the mean difference with a 95% confidence interval for continuous variables and proportion estimation with a fixed-effects model for categorical variables.

In the first step, all FAST domains showed worse FI in patients than in healthy controls, with significant differences between groups. In the second step, the prevalence of FI domains were as follows: global, 58.6%; occupational, 65.6%; cognitive, 49.2%; autonomy, 42.6%; interpersonal relationships, 42.1%; leisure, 29.2%; and financial issues, 28.8%. Residual depressive symptoms were the most frequently cited variable associated with FI.

This study reinforces the relevant functional impact of BD in this population and suggests that the occupational domain may be the most impaired. Greater efforts should be directed toward targeting functioning in patient care, as it constitutes the most meaningful endpoint of response to treatment, especially with occupational and cognitive rehabilitation, thus allowing patients to overcome the course of illness and carry fulfilling lives.

The aim of this study was to investigate the factors associated with illness insight and medication adherence in bipolar disorder (BD). This is a cross-sectional study (with a retrospective evaluation of longitudinal variables) and a secondary analysis of a BD database. The insight of 108 outpatients (age, 48.2 ± 14.1 years, 69% women, 33% euthymic) was measured with three items of the Association of Methodology and Documentation in Psychiatry scale. Their adherence was assessed through patients' and caregivers' reports, plus serum levels. We performed multivariate logistic regression analyses. Full insight was independently and directly associated with adherence, a social support score, and depressive symptoms and inversely associated with intensity of manic symptoms, problems ever with alcohol, and age at onset of the first symptoms. Medication adherence was independently and directly associated with insight, being married, and having had a psychiatric hospitalization and inversely with having suffered a high number of depressive episodes, intensity of manic symptoms, and heavy tobacco smoking.

Background: Evidence indicates that the serum concentration of uric acid (UA) in patients may relate both to the pathophysiology and therapeutics of bipolar disorder (BPD). The purpose of this study was to examine the changes and clinical significance of serum UA concentrations in first-episode manic patients suffering from BPD. Methods: Seventy-six drug-naive patients with first-episode bipolar mania and 76 age- and gender-matched healthy subjects were recruited. Young Mania Rating Scale and Hamilton Depression Rating Scale were used to assess clinical symptoms. We tested serum UA concentrations by sandwich enzyme-linked immunosorbent assay at baseline and at the end of 8-week treatment in BPD patients and in the control group. Results: After 8-week quetiapine and sodium valproate treatment, this study revealed that the serum UA concentrations in remitted patients were significantly lower than nonremitted patients; however, those remitted patients still had higher serum UA than healthy controls. We discovered that the baseline UA concentration was higher in nonremitted than remitted patients after 8 weeks of treatment. Finally, a positive association was found between serum UA and symptom relief in the first episode of manic disorder patients. Conclusion: Patients with first-episode BPD had high levels of serum UA, which responds to treatment mainly in remitted patients. Our results suggest that serum UA concentrations might present potentially a trait marker in bipolar patients.

Functional impairment is an important driver of disability in patients with bipolar disorder (BD) and can persist even when symptomatic remission has been achieved. The objectives of this systematic literature review were to identify studies that assessed functioning in patients with BD and describe the functional scales used and their implementation.

A systematic literature review of English-language articles published between 2000 and 2017 reporting peer-reviewed, original research related to functional assessment in patients with BD was conducted.

A total of 40 articles met inclusion criteria. Twenty-four different functional scales were identified, including 13 clinician-rated scales, 7 self-reported scales, and 4 indices based on residential and vocational data. The Global Assessment of Functioning (GAF) and the Functional Assessment Short Test (FAST) were the most commonly used global and domain-specific scales, respectively. All other scales were used in ≤2 studies. Most studies used ≥1 domain-specific scale. The most common applications of functional scales in these studies were evaluations of the relationships between global or domain-specific psychosocial functioning and cognitive functioning (eg, executive function, attention, language, learning, memory) or clinical variables (eg, symptoms, duration of illness, number of hospitalizations, number of episodes).

The results of this review show growing interest in the assessment of functioning in patients with BD, with an emphasis on specific domains such as work/educational, social, family, and cognitive functioning and high utilization of the GAF and FAST scales in published literature.

Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.

A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.

The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.

The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.

Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.

Clinical studies have shown that bipolar patients have increased serum uric acid levels. High serum uric acid levels could play a role contributing to high prevalence of metabolic syndrome. Metabolic syndrome is known to increase the risk of developing a number of life threatening diseases including coronary heart disease, hypertension, and type 2 diabetes. This study investigated the association between hyperuricemia and metabolic syndrome and its components in individuals suffering from bipolar disorders.

This study recruited 318 inpatients suffering from bipolar disorders from Beijing Hui-Long-Guan Hospital in China and 160 healthy subjects from the same region as the controls. We used National Cholesterol Education Program Adult Treatment Panel III Adapted criteria (NCEP ATP-III A) for the diagnosis of metabolic syndrome. Hyperuricemia was determined as serum uric acid level above 420 μmol/L in men and 360 μmol/L in women (N Engl J Med 359(17):1811-1821, 2008).

Among 318 bipolar patients, there was higher prevalence of metabolic syndrome (42.5%) and hyperuricemia (27.7%) than healthy controls (21.9 and 11.9%). Bipolar patients with metabolic syndrome had increased prevalence of hyperuricemia (OR = 3.0, CI95 [1.7-5.4]). Hypertriglyceridemia and larger waist circumference (WC) were associated with hyperunicemia (OR = 1.8, CI95 [1.1-3.1], OR = 1.9, CI95 [1.1-3.4]). Hyperuricemia was associated with metabolic syndrome in bipolar patients (p < 0.001) and especially with hypertriglyceridemia (OR = 1.9, CI95 [1.1-3.1] and increased WC (OR = 2.1 [1.2-4.0]). Bipolar patients over 50 years of age and hyperuricemia were highly prone to develop metabolic syndrome (OR = 14.0, CI95 [5.0-39.0]).

Hyperuricemia was highly associated with development of metabolic disorder particularly for aged patients suffering from bipolar disorders. Early prevention of hyperuricemia and metabolic syndrome may lead better life for bipolar patients when they get older.

The clinician patient relationship lies at the core of psychiatric practice and delivery of mental health care services. The concept of treatment alliance in psychiatry has its origins in psychotherapy, but has also been influenced by several other constructs such as patient-centred care (PCC) and shared decision-making (SDM). Similarly, there has been a shift in conceptualization of treatment-adherence in psychiatric disorders including bipolar disorder (BD) from illness-centred and clinician-centred approaches to patient-centred ones. Moreover, the traditional compliance based models are being replaced by those based on concordance between clinicians and patients. Newer theories of adherence in BD place considerable emphasis on patient related factors and the clinician patient alliance is considered to be one of the principal determinants of treatment-adherence in BD. Likewise, current notions of treatment alliance in BD also stress the importance of equal and collaborative relationships, sensitivity to patients' viewpoints, sharing of knowledge, and mutual responsibility and agreement regarding decisions related to treatment. Accumulated evidence from quantitative research, descriptive accounts, qualitative studies and trials of psychosocial interventions indicates that efficacious treatment alliances have a positive influence on adherence in BD. Then again, research on the alliance-adherence link in BD lags behind the existing literature on the subject in other medical and psychiatric conditions in terms of the size and quality of the evidence, the consistency of its findings and clarity about underlying processes mediating this link. Nevertheless, the elements of an effective alliance which could have a positive impact on adherence in BD are reasonably clear and include PCC, collaborative relationships, SDM, open communication, trust, support, and stability and continuity of the relationship. Therefore, clinicians involved in the care of BD would do well to follow these principles and improve their interpersonal and communication skills in order to build productive alliances with their patients. This could go a long way in confronting the ubiquitous problem of non-adherence in BD. The role of future research in firmly establishing the alliance-adherence connection and uncovering the processes underlying this association will also be vital in devising effective ways to manage non-adherence in BD.

The current study focused on the association between resilience and social functioning in patients with bipolar disorder (BD). Forty clinically stable patients with BD type I and BD type II, as well as 40 healthy controls, matched for age, sex, and educational background were enrolled. Clinical status was assessed by the Montgomery-Åsberg Depression Rating Scale and the Young Mania Rating Scale. Functioning was evaluated by the Mini International Classification of Functioning, Disability and Health rating of activities and participation in mental illnesses, and the Social and Occupational Functioning Scale. Resilience was measured by the Connor-Davidson Resilience scale. Patients demonstrated significantly lower resilience levels compared with healthy individuals. A stepwise regression analysis indicated that only resilience contributed significantly to social functioning's outcome. Because resilience may constitute a social functioning moderator in clinically stable patients with BD, a paradigm shift toward protective factors could lead to implementation of resilience-oriented interventions designed specifically for patients with BD.

Data describing bipolar disorder in older adults people are scarce, particularly with regard to functional status. This observational, comparative study assessed psychosocial functioning in 33 euthymic older adults with bipolar disorder compared with 30 healthy controls. In addition, we evaluated the association between clinical variables and poor functioning in the patient group. The mean age of the group was 68.70 years. Patients with bipolar disorder experienced poorer psychosocial functioning (19.15 ± 11.36) than healthy controls (5.17 ± 3.72; p = 0.0001), as assessed using the Functioning Assessment Short Test. Significant differences between the groups were found for specific domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, and interpersonal relationships (p = 0.0001, respectively). The largest variation was observed in overall functioning (Cohen's d = 0.63). The number of previous hospitalizations was strongly associated with poor overall functioning (F = 7.217, p = 0.002). Older patients with bipolar disorder had a greater functional impairment than the healthy control group. Implementation of novel rehabilitation models is critical to help patients manage their illness.

Bipolar disorder (BD) costs the English economy an estimated £5.2billion/year, largely through incomplete recovery. This analysis estimated the cost-effectiveness of group psychoeducation (PEd), versus group peer support (PS), for treating BD.

A 96-week pragmatic randomised controlled trial (RCT), conducted in NHS primary care. The primary analysis compared PEd with PS, using multiple imputed datasets for missing values. An economic model was used to compare PEd with treatment as usual (TAU). The perspective was Health and Personal Social Services.

Participants receiving PEd (n=153) used more (costly) health-related resources than PS (n=151) (net cost per person £1098 (95% CI, £252-£1943)), with a quality-adjusted life year (QALY) gain of 0.023 (95% CI, 0.001-0.056). The cost per QALY gained was £47,739. PEd may be cost-effective (versus PS) if decision makers are willing to pay at least £37,500 per QALY gained. PEd costs £10,765 more than PS to avoid one relapse. The economic model indicates that PEd may be cost-effective versus TAU if it reduces the probability of relapse (by 15%) or reduces the probability of and increases time to relapse (by 10%).

Participants were generally inconsistent in attending treatment sessions and low numbers had complete cost/QALY data. Factors contributing to pervasive uncertainty of the results are discussed.

This is the first economic evaluation of PEd versus PS in a pragmatic trial. PEd is associated with a modest improvement in health status and higher costs than PS. There is a high level of uncertainty in the data and results.

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

Due to the serious and recurrent nature of bipolar disorder, continuous long-term medication treatment is typically recommended. Little is known about whether these treatment recommendations are effectively implemented for Hispanics. This study examined differences in mood stabilizer use and mental health service utilization between adult English-speaking Hispanic and non-Hispanic white respondents with bipolar disorder.

The sample included 163 participants with lifetime bipolar I and II disorders in the National Comorbidity Survey Replication. Demographics, symptom presentation, and acculturation were examined as covariates.

None of the 26 Hispanic respondents were taking mood-stabilizing medication, compared to 21 % of non-Hispanic whites, and Hispanics were less likely to receive medications for emotional problems, see a professional for manic episodes, or attend psychotherapy. Even after accounting for differences in symptom profiles and sociodemographics, ethnicity continued to be a significant predictor of mood stabilizer use and psychotherapy attendance. There was a non-significant trend toward lower acculturation among Hispanics being associated with even poorer service utilization.

No Hispanics were receiving minimally adequate treatment for their bipolar disorder. Future research should focus on identifying the barriers that lead to these stark ethnic disparities in treatment.

Although it is undisputable that patients with severe mental illness have impaired ability to work, the extent of this is unclear. This is a nation-wide, cross-sectional survey of patients who have been hospitalized with severe mental illness earning minimum wage or above.

Data from the Israeli Psychiatric Hospitalization Case Registry were linked with nation-wide data from the National Insurance Institute (the equivalent of US Social Security) on personal income. Hospitalization data were obtained on all consecutive admissions to any psychiatric hospital in the country between 1990-2008 with a diagnosis of schizophrenia, other nonaffective psychotic disorders, or bipolar disorder (N = 35 673). Earning minimum wage or more was defined as earning at least 1000 USD/month, which was equivalent to minimum wage in Israel in December 2010.

The percentages of patients with only 1 admission who were earning minimum wage or above in December 2010 were as follows: 10.6% of patients with a diagnosis of schizophrenia; 21.6% of patients with a diagnosis of nonaffective psychotic disorders; and 24.2% of patients with bipolar disorder. The percentages of patients with multiple admissions who were earning minimum wage or above were as follows: 5.8% of patients with schizophrenia; 11.2% of patients with nonaffective psychotic disorders; and 19.9% of patients with bipolar disorder.

Despite potential confounders, the results indicate that patients with schizophrenia, nonaffective psychotic disorders, or bipolar disorder have a poor employment outcome, even if they have only been admitted once. These results emphasize the importance of improving interventions to re-integrate these individuals into the work force.

The reciprocal relationship between bipolar disorder (BD) and the family system highlights the importance of adjunctive family intervention. However, its implementation in clinical practice is not widespread. To update the knowledge in this field and identify areas of uncertainty this manuscript present a comprehensive overview of the bidirectional relationship between BD and family variables, and a systematic review of the evidence-based studies published up to March 2015 on the efficacy of adjunctive family intervention in BD. Findings show that not only specific family's attitudes/interactions affect the course of BD but that equally the illness itself has a strong impact on family functioning, caregivers' burden and health. Regarding family intervention, there are methodological differences between studies and variability in the sample characteristics and the intervention used. Most evidence-based studies support the efficacy of adjunctive family treatment in the illness outcomes, both in youth and adult population, as well as benefits for caregivers. The results emphasize the need to involve caregivers in the therapeutic management of BD through tailored interventions based on patients' characteristics and family needs.

Bipolar disorder (BD) is associated with significant impairment in cognitive performance across multiple domains of function that often persist after clinical recovery. It remains unclear, however, as to whether this process is related to the clinical status of BD being depressed, manic/hypomanic, or euthymic. In this review, we examine the literature on the cross-sectional and longitudinal relationships between cognitive function and general function depending on the clinical phase of BD.

A systematic review of original research that studied both cognitive function and general function in adults (18-60 years), restricted to BD, was conducted in a total of 18 studies meeting inclusion/exclusion criteria.

Results show cross-sectional and prospective relationships between cognitive function and general function in patients with BD in both symptomatic and euthymic patients with BD. While studies using general measures of function (e.g., Global Assessment of Function scale) show more inconsistent associations with cognitive function, those employing assessments of domain specific function, suggest a consistent relationship between social and occupational function and cognitive performance. Executive function is commonly affected by cognitive deficits in these patients, but in addition a variety of domains show associations with functional outcomes (e.g., social function, occupational function). Notably, the emerging evidence suggests that cognitive function may be a better predictor of future general function than affective symptom severity.

Despite some inconsistencies, in sum the literature on the relationship between cognitive function and general function in BD implicates both cross-sectional and longitudinal associations, both in symptomatic and euthymic patients with BD. And in terms of capturing these changes functional scales in particular domain-specific measures seem superior to general measures.

Recent research in bipolar disorder (BD) points to the relevance and persistence of cognitive deficits even in euthymia. Up to now, the mechanisms behind why some bipolar patients (BP) do not reach their former level of cognitive performance and psychosocial functioning while others remit completely, are not understood. In this study we aimed to identify a "cognitive deficit" vs. "non-deficit" subgroup within BD by using an extensive neuropsychological test battery. The test performance of 70 euthymic outpatients (BD-I and II, recruited as a sample of convenience from our bipolar disorder programme) was compared to 70 matched, healthy controls (HC). Furthermore, we investigated the association between demographic/clinical variables and the cognitive performance of BP. As expected, our sample of euthymic BP performed significantly worse than HC in psychomotor speed, divided attention, working memory, verbal memory, word fluency and problem solving. However, 41.4% of the patients did not have any neurocognitive deficits at all, and whether or not a patient belonged to the non-deficit group was not influenced by disease severity. Instead, our results demonstrate that patients suffering from persistent sleep disturbances and sub-threshold depressive symptomatology show more severe cognitive dysfunctions. In addition, antipsychotic treatment and comorbid anxiety disorder were associated with cognitive deficits. In sum, these results suggest that a major part of cognitive impairment is due to current symptomatology, especially sleep disorder and sub-syndromal depression. Rigorous treatment of these symptoms thus might well improve cognitive deficits and, as a consequence, overall functioning in BD.

The aim of the present review was to examine objective and subjective burdens in primary caregivers (usually family members) of patients with bipolar disorder (BD) and to list which symptoms of the patients are considered more burdensome by the caregivers. In order to provide a critical review about caregiver's burden in patients with bipolar disorder, we performed a detailed PubMed, BioMedCentral, ISI Web of Science, PsycINFO, Elsevier Science Direct and Cochrane Library search to identify all papers and book chapters in English published during the period between 1963 and November 2011. The highest levels of distress were caused by the patient's behavior and the patient's role dysfunction (work, education and social relationships). Furthermore, the caregiving role compromises other social roles occupied by the caregiver, becoming part of the heavy social cost of bipolar affective disorder. There is a need to better understand caregivers' views and personal perceptions of the stresses and demands arising from caring for someone with BD in order to develop practical appropriate interventions and to improve the training of caregivers.

Temperament originates in the brain structure, and individual differences are attributable to neural and physiological function differences. It has been suggested that temperament is associated with metabolic syndrome (MetS) markers, which may be partly mediated by lifestyle and socioeconomic status. Therefore, we aim to compare MetS prevalence between different affective temperamental profiles for each season in bipolar patients.

Twenty-six bipolar type-I patients of a specialized outpatient mood disorder unit were evaluated for MetS according to new definition proposed by the International Diabetes Federation in the four seasons of a year. Temperament was assessed using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego - autoquestionnaire version (TEMPS-A).

The proportions of MetS were 19.2, 23.1, 34.6, and 38.5% in the summer, fall, spring, and winter, respectively. Only depressive temperament scores were higher (p = 0.002) during the winter in patients with MetS.

These data suggest that depressive temperament profiles may predispose an individual to the development of MetS in the winter.

To study social functioning, and its relationship with clinical and neurocognitive variables, in patients having their first treatment contact for a manic episode.

A total of 55 first contact mania patients, 34 with a first manic episode (FM) and 21 with previously untreated manic episodes (PM), and 110 healthy control subjects matched for age, sex and education to the patient group, completed the Social Functioning Scale (SFS), a self-reported assessment of social functioning. The patients also completed a broad neuropsychological test battery.

Both patient groups scored significantly lower on self-rated social functioning compared to healthy controls, with PM patients reporting significantly lower functioning than FM patients. There were no significant correlations between clinical symptoms and social functioning. On a trend level, a reduced SFS score was associated with more cannabis use, higher levels of depression and more depressive episodes as well as an earlier age at onset. There was no significant association between social function and neurocognition.

Social dysfunction was present in patients with BD at first treatment contact-the main predictors of which being the severity of clinical symptoms.

The objectives were to assess the characteristics of patients with bipolar disorder (BD) and to evaluate the prescribing practices.

MONTRA is a quantitative survey conducted between December 2010 and February 2011. Data were extracted by the psychiatrists from the medical files of BD patients seen on four consecutive days of consulting.

Four hundred and thirty-nine psychiatrists included 2529 patients (inpatients, n=319; outpatients from mental clinics, n=1090; outpatients consulting in private practice, n=1020). In the total patient population (mean age: 47 years; women, 58%), BD was distributed as follows: BD type I, 56%; BD type II, 40%; other types of BD, 4%; rapid cyclers, 10%. The prevalence of psychiatric comorbidities was high (anxiety disorders, 48%; abuse and dependence on toxic substances, 17 and 10% respectively), 36% of the patients had a history of suicide attempt and the risk of suicide, when assessed, was 6%. In about half the patients (48%), the polarity of the initial bipolar episode was of the depressive type (versus 39% for the manic/hypomanic type). Outpatients were globally independent and did not require assistance in the management of their disease or its treatment whereas the social and professional lives of inpatients were negatively affected by their condition. Based on the psychiatrist's declarations, 39 to 50% of the outpatients were symptom-free, 36 to 40% were in the intercurrent phase with residual symptoms, 11 to 17% presented either a manic or depressive acute BP episode, and 3 to 4% were in a mixed state; among inpatients, 52% presented an acute episode either manic or depressive, 38% were in the intercurrent phase and 9% were in a mixed state. In the symptomatic patients from the total population (61%), the most prevalent symptoms were depressive and corresponded to acute symptoms (patients with a depressive episode, 14%) or residual symptoms (patients in the intercurrent phase, 27%). The predominant depressive polarity was observed in both hospitalized and outpatients. The pharmacological treatment of BD included polytherapy in 73% of the patients. In the manic episodes (n=126), the patients were treated with a Mood Stabilizer (MS, 56%) or an atypical antipsychotic (AAP, 52%) in association. In the depressive episodes (n=342), the patients received an antidepressant drug associated with a MS or an AAP (70%). In symptom-free or symptomatic intercurrent periods (n=1943), the patients were treated with a MS (49-58%) or an AAP (37-49%), in association.

BD patients evaluated in our survey were in majority diagnosed with BD type I, associated with considerable comorbidity. In the symptomatic patients, the most prevalent symptoms, either acute or residual, were of the depressive type. In the majority of the patients, whatever the clinical status, polytherapy was prescribed for the BD.

Bipolar disorder (BD), over the long term, can manifest a variety of outcomes depending on a number of different conditions. There is a need for further knowledge regarding preventive factors as well as predictors of the disabling course of the disorder. Studies regarding the impact on functional outcome of premorbid and current general intellectual function [intelligence quotient (IQ)] and premorbid functioning in BD patients are sparse. The present study addressed the role of premorbid functioning [assessed with the Premorbid Adjustment Scale (PAS)], intelligence, course of illness, and sociodemographics on occupational outcome in BD.

Bipolar disorder patients were recruited consecutively from psychiatric units (outpatient and inpatient) in four major hospitals in Oslo, Norway [(N = 226: 64.4% bipolar I disorder (BD-I); 30.1% bipolar II disorder (BD-II); 5.5% bipolar disorder not otherwise specified (BD-NOS); 38.6% males]. The associations between current IQ, premorbid IQ [assessed using the National Adult Reading Test (NART)], PAS, clinical and sociodemographic characteristics, and receipt of disability benefit were analysed using descriptive statistics and logistic regression analyses.

The number of hospitalizations for depressive episodes and illness duration was associated with a higher risk of receipt of disability benefit. PAS, premorbid and current IQ, as well as decline in IQ, did not explain the higher risk of receipt of disability benefits.

Severe clinical course of BD was associated with receipt of disability benefit. Occupational outcome was unrelated to PAS, premorbid and current IQ, as well as decline in IQ. This suggests that the persistence of severe clinical symptoms, rather than global cognitive functioning, determines occupational outcome in BD and emphasizes the protective potential of early and continuous clinical treatment.

Severe work impairment can be present for a considerable proportion of the course of bipolar disorder (BD) and is costly for governments, services and individuals. Understanding predictors of employment in BD is therefore crucial as some may be susceptible to interventions. We conducted a systematic review of prospective studies in order to identify predictors of employment in people with BD.

We searched Medline, PsychInfo, EMBASE and Web of Science databases, hand searched 3 journals and used predetermined criteria to select papers for full text inclusion. Sixty seven papers were identified. Nine met inclusion criteria, with a total sample of 3184.

Studies included in this review identified cognitive deficits (67%, n=4), depression (43%, n=3) and level of education (33%, n=2) as predictors of employment in BD patients. Bipolar depression not only affects whether someone is employed but also time off work. Even sub-syndromal depression appears to damage employment prospects. Verbal memory and executive functioning appear to be predictors of work functioning.

Conclusions are based on a relatively small number of studies and are therefore subject to change with the addition of further studies. A formal meta-regression was not possible due to differences between measures of employment and work functioning.

Better assessment and management of depression and cognitive difficulties could improve the occupational functioning of BD patients. There is a need for high quality longitudinal studies specifically designed to investigate predictors of employment in large bipolar disorder samples.

Many people with mental illness experience stigma that has impacted their lives. In this study, we validated the Inventory of Stigmatizing Experiences (ISE) as a tool to help quantify the stigma experienced by patients with bipolar disorder and its impact on their lives. The ISE has two components, ie, the Stigma Experiences Scale (SES) and the Stigma Impact Scale (SIS), which were administered to a population of Argentinean patients with bipolar disorder. We characterized the differences between these two populations using the SES and SIS. Finally, we compared SES and SIS scores with those in a population of Canadian patients with bipolar disorder.

The SES and SIS scales were administered to tertiary care patients with bipolar I and II disorder in Argentina (n = 178) and Canada (n = 214).

In this study, we validated both SES (Kuder-Richardson coefficient of reliability, 0.78) and SIS (Cronbach's alpha, 0.91) scales in a population of Argentinean patients with bipolar disorder. There were no significant differences in stigma between patients with bipolar I or II disorder on SES or SIS. However, over 50% of all respondents believed that the average person is afraid of those with mental illnesses, that stigma associated with mental illness has affected their quality of life, and that their self-esteem has suffered due to stigma. In comparison with the Canadian population, Argentinean participants scored lower on both the SES and SIS, which may be due to cultural differences or to differences in population characteristics.

Stigma associated with mental illness is serious and pervasive. If we are to find successful strategies to mitigate stigma, it is first important to understand how patients perceive such stigma. The ISE is a valuable tool which allows us to do this with high reliability among cultures.

Studies on adult bipolar patients have demonstrated a disability associated with the bipolar disorder, even in euthymic patients, but there is a lack of data in the elderly population.

A cross-sectional, multicentre study on a consecutive sample of ambulatory bipolar patients (DSM-IV-TR criteria), aged 65 years or over. Retrospective and cross-sectional sociodemographic and clinical data were collected, as well as the Clinical Global Impression for Bipolar Modified scale (CGI-BP-M) and the level of disability using the World Health Organisation Disability Assessment Schedule (WHO/DAS). The disability was assessed globally and by areas. The presence of a moderate to maximum disability compared to a mild to no disability was considered a dependent variable.

A moderate to maximum global disability was present in 43.6% of the sample. By areas, occupational functioning was the area most frequently affected, and personal care the least affected. The only variables which were associated with disability were the presence of medical comorbidity (P = .01), increased age (P = .005) global clinical severity (P = .0001) and in the depressive pole (P = .03). There was no relationship between clinical subtype, duration of the disease, number of previous episodes, number of hospitalisations, or other clinical variables and the degree of disability.

These data underline the need to establish specific therapeutic strategies in the approach to depressive symptoms and medical comorbidity, with the aim of minimising the disability in elderly bipolar patients. Given the lack of current data, new studies are needed with larger samples and control groups.

To analyze demographical, clinical, and therapeutic variables that may be associated with pharmacological non-adherence in a sample of schizoaffective patients, bipolar type.

Adherence to treatment and its clinical correlates were assessed at the end of a 10-year follow-up in 76 patients meeting DSM-IV-TR diagnosis of schizoaffective disorder, bipolar type. Adherent and poorly adherent patients were compared regarding clinical and therapeutic variables.

The rate of poorly adherent patients was 32/76 (41.2%) of the sample. Adherent patients were more likely to have presented an affective episode at illness onset and to have fewer purely - non-affective - psychotic episodes. Demographic or other clinical variables were not found to be associated to treatment adherence. Family history for psychiatric disorders or suicide did not correlate either, and neither did any specific pharmacological agent.

Rates of non-adherence in schizoaffective disorder are high. Adherence seems to be associated to a more affective course of illness (affective first episode and fewer purely psychotic episodes). Patients with more prominent schizophrenia-like characteristics could be at higher risk for poor adherence and need to be closely followed and monitored. Even when properly treated, schizoaffective disorder is a disabling and severe disorder with high risk for recurrences.

The ECHO study is the first French study directly asking patients with bipolar I disorders on the history and experiences of their disease, their perceptions of care, their sociofamilial relationships, and their expectations regarding what should be done by healthcare professionals and their environment.

Three hundred euthymic patients suffering from bipolar disorder I were interviewed using a semi-standardized evaluation through telephone interviews. These patients were selected according to the quota method of nationally representative INSEE 99 to be representative of the French population.

Ninety-nine percent of patients consulted at least once for psychological signs before the correct diagnosis was established. The average age at the time of diagnosis was of 30.1 years (± 11.3). The average time between first consultation for psychological symptoms and diagnosis is about 5 years. In 92% of cases, the psychiatrist is the health professional that made the diagnosis; 74% of patients were also followed by a general practitioner. One hundred percent of participants had been hospitalized for manic episodes (criterion for inclusion in the study) and 86% were also hospitalized for depressive symptoms. The experience of hospitalization is positive (feeling of security for 84% of the sample, feelings of being helped for 81% of the sample), although these experiences are also associated with the perception of confinement (52% of the sample). At the time of the interview, 97% of these patients were followed by one or more health professionals. Only 34% of these patients were taking a mood stabilizer (lithium, anticonvulsant or atypical antipsychotic with indications in France for bipolar disorder), while 44% were taking an antidepressant and 38% were taking anxiolytics; 84% of patients had experienced side effects related to their current treatment. Acceptance of the disease is difficult and only 56% of patients personally feel they suffer from bipolar disorders. Patients believe that their mental health problems have a significant impact on their lives, including impact on their self-esteem and happiness. Relationships with family, friends but also sexual relations are affected. Even in the euthymic phase, 44% of patients have difficulties in their daily tasks. Three quarters of patients said they had already experienced rejection or discrimination related to their disease. Finally, patients gave a score of 6.4 out of 10 to assess the impact of the disorder on their quality of life. Patients request more dialogue with health professionals and a more personalized treatment, taking into account side effects. They also want more information on the treatment. They would also like to be supported, together with their families, and advised on how to cope with the disease.

Recognising early warning signs (EWS) of mood changes is a key part of many effective interventions for people with Bipolar Disorder (BD). This study describes the development of valid and reliable checklists required to assess these signs of depression and mania.

Checklists of EWS based on previous research and participant feedback were designed for depression and mania and compared with spontaneous reporting of EWS. Psychometric properties and utility were examined in 96 participants with BD.

The majority of participants did not spontaneously monitor EWS regularly prior to use of the checklists. The checklists identified most spontaneously generated EWS and led to a ten fold increase in the identification of EWS for depression and an eight fold increase for mania. The scales were generally reliable over time and responses were not associated with current mood. Frequency of monitoring for EWS correlated positively with social and occupational functioning for depression (beta=3.80, p=0.015) and mania (beta=3.92, p=0.008).

The study is limited by a small sample size and the fact that raters were not blind to measures of mood and function.

EWS checklists are useful and reliable clinical and research tools helping to generate enough EWS for an effective EWS intervention.