Stigma: a core factor on predicting functionality in bipolar disorder

doi:10.1016/j.comppsych.2011.08.010

Comprehensive Psychiatry

Volume 53, Issue 5, July 2012, Pages 484-489

https://doi.org/10.1016/j.comppsych.2011.08.010 Get rights and content

Abstract

Objective

Extant literature indicates that bipolar disorder (BD) is associated with significant poor psychosocial functioning. However, the relationship between functioning and demographic and clinical variables is unclear. The aim of this study is to investigate the predictors of functioning such as demographic and clinical variables, social support, self-perceived stigma, and insight in remitted patients with BD.

Methods

Eighty patients with a diagnosis of BD, complete remission according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were included in the final assessment. Bipolar Disorder Functioning Questionnaire, Beck Depression Inventory, Young Mania Rating Scale, Internalized Stigma of Mental Illness Scale, Multidimensional Scale of Perceived Social Support, and Schedule for Assessing the Three Components of Insight were used. Student t test, Pearson correlation analyses, and linear regression analyses were used to assess the pathways effecting on functioning.

Results

The 3 predictors of functioning were severity of depression, perceived social support, and internalized stigmatization. Severity of depression is considered the strongest predictor, whereas internalized stigmatization has a core role in predicting functioning. Clinical variables such as years of education and number of hospitalization probably have indirect effects on functioning.

Conclusion

Interventions that oppose stigmatization and consideration of mild depressive symptoms will positively affect functioning in remitted patients with BD.

Introduction

According to the World Health Organization (WHO), bipolar disorder (BD) is the sixth cause of disability among all other diseases [1]. Impairment among adults with BD is not limited to symptomatic periods but persists even during periods of remission [2], [3]. After a relapse, only 40% of the patients achieve premorbid functional outcome during euthymia [4]. Thus, one of the main targets of treatment of BD should be the improvement in functioning, and in the remission period, the main outcome of the treatment should be normal level of functioning. BD is associated with profound impairment in nearly every domain of functioning [5]. It is associated with significant psychosocial, marital, interpersonal, and occupational impairment [6], [7].

Extant literature indicates that BD is associated with significant poor psychosocial functioning; however, the relationship between functioning and demographic and clinical variables is unclear and requires further examination. Therefore it is necessary to identify the factors that contribute to this disability.

Rosa et al [8] found that older age, depressive symptoms, number of previous mixed episodes, and number of previous hospitalizations predict poor functioning. In another study, the clinical variables that significantly predicted functioning were total number of episodes, number of depressive episodes, family history of psychiatric disorders, mild subdepressive symptoms, and perceived social support [9]. Wingo et al [10] found that among euthymic or mildly depressed bipolar patients, functional recovery was associated with higher education, fewer years of illness, and being married. Hajek et al [11] found decreased functioning in patients with chronic illness, history of rapid cycling type of bipolar disorder, suicidal behavior, psychiatric comorbidity, and other medical conditions such as hypothyroidism and diabetes mellitus. A recent preliminary study investigating the impact of stigma and functioning in bipolar patients demonstrates that high scores of self-perceived stigma were correlated with lower scores of functioning [12].

The aim of this study is to investigate the predictors of functioning such as demographic and clinical variables, social support, self-perceived stigma, and insight in remitted patients with BD.

Section snippets

Study design

This study was accomplished in the outpatient psychiatry clinic in Haydarpaşa Numune Training and Research Hospital between July 7, 2008, and November 7, 2008. Patients with a diagnosis of bipolar disorder, complete remission according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were included the study. Considering their possible effects on functioning, patients with a diagnosis of mental retardation, chronic physical disease, alcohol or substance use disorder,

Results

The mean functioning (BDFQ) scores of the patients and the relationship between demographic and clinical variables with functioning are presented in Table 1, which shows that there is no relation between functioning and sex, marital status, occupation, and psychotic-featured episodes.

The correlations of demographic and clinical variables with functioning are presented in Table 2. The variables that have significant correlation with functioning were severity of depression, internalized

Discussion

In this study, the term functioning mainly expresses “social functioning,” including social withdrawal, household relations, participation in social activities, daily activities and hobbies, taking initiative and self-sufficiency, occupation, and others. Functioning has been extensively studied in schizophrenia, with less focus on remitted bipolar patients. The fact that bipolar patients struggle with serious functional loss indicates the need to study this loss and the factors related to it.

References (31)

G.H. Vazquez et al.
Stigma and functioning in patients with bipolar disorder
J Affect disord
(2011)
C.M. Bonnin et al.
Clinical and neurocognitive predictors of functional outcome in bipolar euthymic patients: A long term, follow-up study
J Affect Disord
(2010)
C.D. Morris et al.
Care satisfaction, hope and life functioning among adults with bipolar disorder: data from the first 1000 participants in the Systematic Treatment Enhancement Program
Compr Psychiatry
(2005)
A.P. Wingo et al.
Correlates of recovery of social functioning in types I and II bipolar disorder patients
Psychiatry Res
(2010)
V.V. Dias et al.
Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder
J Affect Disord
(2008)
C. Murray et al.
The global burden of disease. A comprehensive assessment of morbidity and disability from diseases, injuries and risk factors in 1990 and projected to 2020
(1996)
A. Fagiolini et al.
Functional impairment in the remission phase of bipolar disorder
Bipolar disord
(2005)
R. Morriss
Clinical importance of inter-episode symptoms in patients with bipolar affective disorder
J Affect Disord
(2002)
M.P. Delbello et al.
Twelve-month outcome of adolescents with bipolar disorder following first hospitalization for a manic or mixed episode
Am J Psychiatry
(2007)
L. Judd et al.
Psychosocial disability in course of bipolar I and II disorders: a prospective, comparative longitudinal study
Arch Gen Psychiatry
(2005)

W. Coryell et al.

The enduring psychosocial consequences of mania and depression

Am J Psychiatry

(1993)

J.F. Goldberg et al.

Course and outcome in bipolar affective disorder: a longitudinal follow-up study

Am J Psychiatry

(1995)

A.R. Rosa et al.

Clinical predictors of functional outcome of bipolar patients in remission

Bipolar Disord

(2009)

J. Sanchez-Moreno et al.

The role and impact of contextual factors on functioning in patients with bipolar disorder

Disabil Rehabil

(2010)

A.P. Wingo et al.

Factors associated with functional recovery in bipolar disorder patients

Bipolar Disord

(2010)

Cited by (78)

Childhood trauma and self-stigma in mood disorders
2023, Psychiatry Research Communications
Childhood maltreatment and mood disorders are associated and linked to self-stigma. In this study, we assessed the relationship between childhood trauma and self-stigma in patients with mood disorders. Patients with bipolar disorder (n = 69) and unipolar disorder (n = 111) were recruited from the Mood Disorders Unit of the Geneva University Hospitals in Switzerland. All participants underwent a semi-structured interview to assess mood disorder and fulfilled the Internalized Stigma of Mental Illness (ISMI) scale and the Childhood Trauma Questionnaire (CTQ). The results showed that overall self-stigma was not significantly different between the groups. Linear regression modeling revealed that the ISMI total score was significantly associated with the CTQ total score (estimate = 0.01, p = 0.045). Our findings support the assumption that childhood trauma promotes the development of self-stigma in patients with mood disorders. Therefore, this study underscores the importance of assessing childhood trauma in the management of self-stigma in patients with unipolar and bipolar disorder.
Self-stigma and bipolar disorder: A systematic review and best-evidence synthesis
2023, Journal of Affective Disorders
Bipolar disorder is a severe and chronic mental illness characterized by recurrent major depressive episodes and mania or hypomania. In addition to the burden of the disease and its consequences, self-stigma can impact people with bipolar disorder. This review investigates the current state of research in self-stigma in bipolar disorder.
An electronic search was carried out until February 2022. Three academic databases were systematically searched, and best-evidence synthesis was made.
Sixty-six articles were related to self-stigma in bipolar disorder. Seven key themes were extracted from these studies: 1/ Comparison of self-stigma in bipolar disorder and other mental illnesses, 2/ Sociocultural context and self-stigma, 3/ Correlates and predictors of self-stigma, 4/ Consequences of self-stigma, 5/ Treatments and self-stigma, 6/ Management of self-stigma, and 7/ Self-stigma and recovery in bipolar disorder.
Firstly, a meta-analysis could not be performed due to the heterogeneity of the studies. Secondly, limiting the search to self-stigma has excluded other forms of stigma that also have an impact. Thirdly, the under-reporting of negative or nonsignificant results due to publication bias and unpublished studies might have limited the accuracy of this reviews' synthesis.
Research on self-stigma in persons with bipolar disorder has been the focused on different aspects, and interventions to reduce self-stigmatization have been developed, but evidence of their effectiveness is still sparse. Clinicians need to be attentive to self-stigma, its assessment, and its empowerment in their daily clinical practice. Future work is required to establish valid strategies to fight self-stigma.
Evaluation of cognitive insight, social functionality, and coping attitudes of patients diagnosed with schizophrenia being followed-up in a community mental health center
2023, Archives of Psychiatric Nursing
This study was conducted to evaluate the cognitive insight, social functionality, and coping attitudes of patients diagnosed with schizophrenia being followed-up in a Community Mental Health Center (CMHC).
The population of this descriptive and relationship-seeking study comprised 170 schizophrenia patients followed-up in the CMHC. Study data were collected using the Information Form, the Beck Cognitive Insight Scale (BCIS), the Social Functioning Assessment Scale (SFAS), and the Coping Orientation of Problem Experience (COPE).
A moderately significant positive correlation between cognitive insight and social functionality was determined. It was found that participants with high cognitive insight and social functionality used more problem- and emotion-focused coping methods.
It is thought that practices that improve cognitive insight and social functionality will contribute to the rehabilitation of patients with schizophrenia by supporting their coping skills.
Self-stigma and functioning in patients with bipolar disorder
2023, Encephale
Dans ce travail, nous nous sommes proposés d’évaluer l’auto-stigmatisation chez les patients atteints de trouble bipolaire, de relever les facteurs sociodémographiques et cliniques qui lui sont associés et d’étudier l’impact de l’auto-stigmatisation sur le fonctionnement de ces patients.
Nous avons mené une étude transversale, descriptive et analytique incluant 61 patients atteints de trouble bipolaire qui se sont présentés à la consultation de post-cure. Nous avons utilisé l’internalized stigma of mental illness (ISMI) pour étudier l’auto-stigmatisation, et le functioning assessment short test (FAST) pour l’étude du fonctionnement.
L’âge moyen des patients était de 43,4 ans. Le sexe ratio était de 2,4. Plus de la moitié de nos patients (59 %) étaient auto-stigmatisés. L’évaluation du fonctionnement a permis d’estimer une déficience globale chez plus des deux tiers des patients (71 %). Des scores moyens d’auto-stigmatisation significativement plus élevés étaient retrouvés chez les patients célibataires ou divorcés, ceux à bas niveau socio-économique, et en présence d’antécédents judiciaires. En outre, le score moyen d’auto-stigmatisation était associé à un nombre total plus élevé des épisodes thymiques et des hospitalisations, à une durée cumulée plus longue des hospitalisations, à une durée plus courte de la dernière rémission et à un fonctionnement plus altéré.
Notre étude souligne la nécessité d’œuvrer afin de mettre en place des modalités de prise en charge, visant à lutter contre l’auto-stigmatisation des patients atteints de trouble bipolaire et à atténuer ses conséquences négatives sur le cours évolutif de la maladie et le fonctionnement des patients.
Self-stigma of people with bipolar disorder is an underestimated problem, with serious consequences in terms of clinical severity and social and professional functioning.
This study aimed to evaluate self-stigma in patients with bipolar disorder, to identify socio-demographic and clinical factors associated with it and to analyze the links between self-stigma and functioning in this population.
We conducted a cross-sectional, descriptive and analytic study including 61 patients with bipolar disorder meeting criteria of remission. We used the internalized stigma of mental illness (ISMI) to investigate self-stigma, and the functioning assessment short test (FAST) to assess functioning.
The mean age of patients was 43.4 years. The sex ratio was 2.4. Half of the patients were single or divorced (50 %). They had secondary or university education in 69 % of cases and were professionally inactive in 59 % of cases. The socioeconomic level was low or medium in 92 % of cases. A personal judicial record was found in 16 % of patients, a suicide attempt in 41 % of cases. Most patients in our series had bipolar I disorder (92 %). The mean age at onset of the disease was 23.5 years, with a mean duration of disease progression of 20 years. Patients were hospitalized an average of 5.9 times. Most patients (90 %) exhibited psychotic features during their mood relapses. The mean duration of the last remission was 27.9 months. Patients had regular follow-ups at our consultations in 87 % of cases. Among the patients included in the study, 8 % were on long-acting neuroleptics. The mean score on the internalized stigma of mental illness was 2.36 ± 0.56. More than half of our patients (59 %) were self-stigmatized. Discrimination and alienation were found in 51 % of cases, followed by resistance to stigmatization (43 %) and assimilation of stereotypes (41 %). Regarding functioning, a global impairment was noted in more than two thirds of patients (71 %). An alteration in professional functioning was found in 82 % of cases and in cognitive functioning in 69 % of cases. Disruption of the financial sphere concerned 43 % of the patients, and the relational sphere 41 % of them. Autonomy was altered in 41 % of patients. Analysis of the relationships between self-stigma and characteristics of the study population revealed statistically significant associations between higher self-stigma scores and single or divorced status, low socio-economic level and judicial record. In terms of clinical parameters, the mean self-stigma score was significantly associated with a higher total number of thymic episodes and hospitalizations, a longer cumulative duration of hospitalizations and a shorter duration of the last remission. In addition, the mean self-stigma score was associated with significantly more impaired functioning.
Our study underlines the need to work towards the implementation of management modalities aimed at combating the self-stigmatization of patients with bipolar disorder and mitigating its negative consequences during the course of the disease.
Predictors of employment status and stability in Bipolar Disorder: Findings from an 8-year longitudinal study
2023, Journal of Affective Disorders
Understanding how Bipolar Disorder (BD) affects employment is limited by cross-sectional or short-term longitudinal designs. The aims for this study are to examine condition-related and other clinical predictors of longitudinal employment status and stability in those with BD compared to healthy controls (HC).
Participants were 358 individuals with BD and HC who were enrolled in the Heinz C. Prechter Longitudinal Study of BD. Participants completed self-report measurements of employment, symptoms, health, personality, life events, and neuropsychological tests at study enrollment, yearly and/or every two months. Repeated measures logistic regression was used to predict employment status and stability.
Those with BD were less likely to be employed than HC. Significant predictors of unemployment in BD include having BD type I, younger age, less years with BD, higher depression, worse processing speed, and worse mental and physical health. Of those with BD, 64 % demonstrated greater employment instability compared to 37 % of HC. History of psychosis, worse memory, physical health, and greater disruption of negative life events significantly predicted employment instability.
The limitations of this study include the generalizability of this sample, a large reliance of self-report measures, and a lack of employment-related factors such as job-type, functioning, performance, and satisfaction. Lastly, the effects of medication, treatment adherence, and treatment optimization were not assessed in this study.
These findings highlight that different aspects of BD are important for being employed versus maintaining stable employment. These findings indicate the need for more effective treatment strategies beyond symptom management.
Effectiveness of Family-Focused Therapy in Bipolar Disorder: A Randomized Controlled Trial
2023, Iranian Journal of Psychiatry and Behavioral Sciences

View all citing articles on Scopus

View full text

Stigma: a core factor on predicting functionality in bipolar disorder

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

J Affect disord

J Affect Disord

Compr Psychiatry

Psychiatry Res

J Affect Disord

The global burden of disease. A comprehensive assessment of morbidity and disability from diseases, injuries and risk factors in 1990 and projected to 2020

Functional impairment in the remission phase of bipolar disorder

Bipolar disord

Clinical importance of inter-episode symptoms in patients with bipolar affective disorder

J Affect Disord

Twelve-month outcome of adolescents with bipolar disorder following first hospitalization for a manic or mixed episode

Am J Psychiatry

Psychosocial disability in course of bipolar I and II disorders: a prospective, comparative longitudinal study

Arch Gen Psychiatry

The enduring psychosocial consequences of mania and depression

Am J Psychiatry

Course and outcome in bipolar affective disorder: a longitudinal follow-up study

Am J Psychiatry

Clinical predictors of functional outcome of bipolar patients in remission

Bipolar Disord

The role and impact of contextual factors on functioning in patients with bipolar disorder

Disabil Rehabil

Factors associated with functional recovery in bipolar disorder patients

Bipolar Disord