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Quality of life in bipolar disorder: A review of the literature Michalak, Erin E; Yatham, Lakshmi N; Lam, Raymond W Nov 15, 2005

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ralHealth and Quality of Life OutcomesssBioMed CentOpen AcceReviewQuality of life in bipolar disorder: A review of the literatureErin E Michalak*, Lakshmi N Yatham and Raymond W LamAddress: Department of Psychiatry, University of British Columbia, Vancouver, CanadaEmail: Erin E Michalak* - emichala@interchange.ubc.ca; Lakshmi N Yatham - yatham@interchange.ubc.ca; Raymond W Lam - r.lam@ubc.ca* Corresponding author    bipolar disorderquality of lifeliterature reviewAbstractA sizable body of research has now examined the complex relationship between quality of life(QoL) and depressive disorder. Uptake of QoL research in relation to bipolar disorder (BD) hasbeen comparatively slow, although increasing numbers of QoL studies are now being conducted inbipolar populations. We aimed to perform a review of studies addressing the assessment of genericand health-related QoL in patients with bipolar disorder.A literature search was conducted in a comprehensive selection of databases including MEDLINEup to November 2004. Key words included: bipolar disorder or manic-depression, mania, bipolardepression, bipolar spectrum and variants AND quality of life, health-related QoL, functional status,well-being and variants. Articles were included if they were published in English and reported onan assessment of generic or health-related QoL in patients with BD. Articles were not included ifthey had assessed fewer than 10 patients with BD, were only published in abstract form or onlyassessed single dimensions of functioning.The literature search initially yielded 790 articles or abstracts. Of these, 762 did not meet ourinclusion criteria, leaving a final total of 28 articles. These were sub-divided into four categories(assessment of QoL in patients with BD at different stages of the disorder, comparisons of QoL inPatients with BD with that of other patient populations, QoL instrument evaluation in patients withBD and treatment studies using QoL instruments to assess outcome in Patients with BD) anddescribed in detail.The review indicated that there is growing interest in QoL research in bipolar populations.Although the scientific quality of the research identified was variable, increasing numbers of studiesof good design are being conducted. The majority of the studies we identified indicated that QoLis markedly impaired in patients with BD, even when they are considered to be clinically euthymic.We identified several important avenues for future research, including a need for more assessmentof QoL in hypo/manic patients, more longitudinal research and the development of a disease-specific measure of QoL for patients with BD.Published: 15 November 2005Health and Quality of Life Outcomes 2005, 3:72 doi:10.1186/1477-7525-3-72Received: 04 August 2005Accepted: 15 November 2005This article is available from: http://www.hqlo.com/content/3/1/72© 2005 Michalak et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 17(page number not for citation purposes)Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72ReviewGood quality of life (QoL) encompasses more than justgood health. At a basic level, it can represent the sum of aperson's physical, emotional, social, occupational andspiritual well-being, the study of which is complicated bythe fact that there is no consensus as to what constitutesQoL. The World Health Organization has described QoLas "individuals' perception of their position in life in thecontext of the culture and value systems in which they liveand in relation to their goals, expectations, standards andconcerns" [1]. This broad, generic conceptualization ofQoL can be distinguished from the more specific conceptof 'health-related quality of life' (HRQOL), which refers tothose aspects of an individual's life that impact directlyupon their health [2] and the more economically-derived'cost-utility' models of QoL. This area of research is furthercomplicated by the understanding that QoL can be highlysubjective, potentially fluid and open to distortion, mak-ing it challenging to measure reliably and accurately. Yet,there is a growing body of evidence to suggest that QoL isan important indicator of well-being, and one that weshould be attempting to capture when assessing thepatient health.The assessment of QoL in medical settings may be of valuein several ways. QoL instruments can provide levels ofinformation not always supplied by traditional outcomemeasures. For example, some instruments such as theSchedule for the Evaluation of Individualized Quality ofLife (SEIQoL) [3] and the Patient Generated Index [4]allow patients to prioritize which life domains are mostimportant to them. While the reduction of symptoms maybe the primary goal of the clinician, it may be that thepatient places more emphasis upon restoring family rela-tionships, or being able to engage in leisure activities.These 'individualized' measures, although sometimes dif-ficult to administer and interpret, put the patient at thecentre rather than at the periphery of assessing the effec-tiveness of treatment interventions. QoL assessments canalso help determine patient preference, allow compari-sons of well-being between different conditions anddetect subtle differences in response to treatment that maybe missed by traditional outcome measures.While a host of studies have now examined QoL inpatients with major depressive disorder (MDD) (forexample, [5-8] until recently few had specifically focusedupon QoL in patients with bipolar disorder (BD). Theslow uptake of QoL research in BD may have occurred inpart because of the absence of a 'disease-specific' measureof QoL for bipolar populations, or because of reservationsabout the ability of patients with BD to reliably and accu-rately complete self-report measures, particularly when inTwo reviews of previous research addressing health-related QoL (HRQOL) in BD have been conducted [9,10].In the first of these, Namjoshi and colleagues (1999)assessed all relevant English-language articles publishedprior to 1999, identifying 10 studies for inclusion. Thestudies proved to be quite heterogeneous, and used a vari-ety of generic and depression-specific instruments toassess different aspects of HRQOL. They also tended to berelatively small (only one study had a sample size inexcess of 100 patients), were conducted in depressed oreuthymic (rather than hypo/manic) patients, and rarelyincluded descriptions of the psychometric properties ofthe instruments they utilized. The authors of the reviewmade a number of suggestions for future research, includ-ing the development of a disease-targeted measure of QoLfor BD, more assessments in acutely manic patients, andmore longitudinal research. The second review conductedby Dean and colleagues (2004) examined studies that hadassessed HRQOL, work-impairment or healthcare costsand utilization in patients with BD published prior toNovember 2002. The review applied a very broad defini-tion of HRQOL, including in this category studies thathad assessed social or physical functioning in isolation(for example, the Global Assessment of Functioning orGAF scale was included as a measure of HRQOL). Usingthis broad definition, the review identified 65 HRQOLarticles. The authors concluded that deficits in HRQOL inpatients with BD are similar to those observed in patientswith unipolar depression and equal or lower than levels ofHRQOL observed in patients with other chronic medicalconditions.Given the recent upsurge of interest in describing QoL inBD, the present study aimed to provide an updated litera-ture review of studies that have assessed both generic andHRQOL in patients with bipolar disorder.Materials and methodsA comprehensive literature search (supplemented byhand searching where appropriate) was conducted in thefollowing databases up to November 2004:MEDLINE (1966–2004)EMBASE (the Excerptra Medica database) (1988–2004)PubMed (1967–2004)PsychINFO (1967–2004)CINAHL (Cumulated Index to Nursing and Allied HealthLiterature) (1982–2004)Page 2 of 17(page number not for citation purposes)a manic phase. American College of Physicians Journal Club (1991–2004)Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Page 3 of 17(page number not for citation purposes)Flowchart of review resultsigure 1Flowchart of review results.A total of 790 potentially relevantreports were initially identified vialiterature and hand searching(conducted up to November 2004)110 articles wereobtained for furtherevaluationA further 82 articles were rejected afterfurther examination.  The authors of 15papers were unable to provide separateQoL results for patients with BD fromstudies that had used heterogeneouspatient populations77 articles excluded asthey were not writtenin English/no abstractwas availableThe abstracts of 713articles were retrieved formore detailed evaluation.603 articles were rejected as they met oneor more of the review’s exclusion criteria(i.e. did not assess multiple domains ofQoL, examined fewer than 10 patientswith BD, were not published in a peer-reviewed journal)28 studies were finally included inthe review, and were classified intofour categoriesAssessment of QoL in patientswith BD at different stages ofthe disorder (N=10)Comparisons of QoL in BDpatients with that of otherpatient populations (N=5)QoL instrument evaluation inBD patients (N=5)Treatment studies using QoLinstruments to assess outcomein BD patients (N=8)Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Table 1: Summary of studies assessing quality of life in patients with bipolar disorderStudy Location Population(s) QoL instrument(s) Main findings and limitationsArnold et al., (2002) US 44 BD patients (38 type I, 5 type II, I NOS)30 back pain patients 2474 general populationSF-36 HRQOL impaired in BD patients compared to non-clinical sample. Chronic back pain patients more impaired in all SF-36 domains except role limitation (emotional) and mental health.Limitation – disparate sample sizes.Atkinson et al., (1997) Canada 37 BD patients69 patients with schizophrenia35 MDD patientsQoL index BD and MDD patients subjectively reported lower QoL than patients with schizophrenia, but schizophrenia group had poorer objectively measured QoL.Limitation – relatively small BD and MDD sample sizes.Bond et al., (2000) US 149 patients with SMI (21 with BD)QOLI Mean overall life satisfaction QOLI scores showed mid-range impairment.Limitation – small sample of patients with BD.Chand et al., (2004) India 50 BD patients in remission20 patients with schizophrenia20 control subjectsQ-LES-Q, WHO-QOL-BREFPatients with BD generally reported better QoL than patients with schizophrenia, and equivalent QoL to control group subjects.Limitation – incomplete matching between groups; unusually low Q-LES-Q scores in control groupCooke et al., (1996)* Canada 68 euthymic BD patients (55 type I, 13 type II)SF-20 SF-20 scores comparable to those reported for patients with MDD. BD type II patients reported poorer HRQOL that BD type I.Limitation – shortcomings of SF-20 compared to SF-36.Dogan et al., (2003) Turkey 26 outpatients with BD stabilized on lithiumWHO-QOL-BREF Significant improvement in general health, physical functioning and social functioning 3 months after a psychoeducation intervention.Limitation – small sample size.Kusznir et al., (2000) Canada 61 euthymic BD patients (47 type I, 14 type II)OPQ One third of sample did not meet criteria for adequate community functioning.Limitation – cross-sectional research design.Leidy et al., (1998) US 62 BD patients, type I (34 euthymic, 28 depressed)SF-36, QLDS, MHI-17 and CFSPsychometric properties of instruments generally in acceptable ranges. Marked impairment in SF-36 scores apparent and QLDS scores lower than reported elsewhere for patients with unipolar MDD.Limitation – test-retest reliability was measured over an unusually long period.MacQueen et al., (1997)Canada 62 euthymic BD patients, type ISF-20 No significant differences in SF-20 scores between psychotic and non-psychotic patients.Limitation – small sample of patients with psychotic symptoms.MacQueen et al., (2000)Canada 64 euthymic BD patients, type ISF-20 Number of previous depressive episodes a stronger determinant of HRQOL than number of previous manic episodes.Limitation – number of previous episodes determined retrospectively.Namjoshi et al., (2002)US 139 BD patients, type I SF-36 Acute treatment with olanzapine resulted in improved SF-36 physical functioning scores; improvement in vitality, pain, general health and social functioning domains apparent in open-label phase.Limitation – adjunctive use of lithium and fluoxetine during open-label phase.Namjoshi et al., (2004)US 224 BD patients, type I QOLI Olanzapine cotherapy associated with better outcome in several QOLI domains compared to monotherapy with lithium or valproate.Limitation – only acute QoL outcome data available.Olusina et al., (2003) Nigeria 25 outpatients with BD type I or IIWHO-QOL-BREF-TR Majority of sample report 'fair/average' QoL. Small sample of patients with BD, little clinical information for sample.Page 4 of 17(page number not for citation purposes)Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Ozer et al., (2002) Turkey 100 interepisode BD patientsQ-LES-Q Depression scores on SADS interview significantly predicted lower Q-LES-Q scores.Limitation – cross-sectional nature of research.Patelis-Siotis et al., (2001)Canada 49 BD mildly depressed or euthymic patientsSF-36 SF-36 vitality and role (emotional) scores significantly improved after CBT.Limitation – Open study, and SF-36 scores only available for a sub-set of patients.Perlis et al., (2004) US 983 patients with BD type I, II or NOSQ-LES-Q Younger age of onset of BD predicts Q-LES-Q scores.Revicki et al., (1997) US 28 outpatients diagnosed with DSM-III-R BDSF-36 Onset of BD determined retrospectively.No significant differences in SF-36 domain scores according to mode of administration (in-person vs. telephone).Limitation – small sample size.Revicki et al., (2003) US 120 BD type I patients hospitalized for acute maniaQ-LES-Q No differential effects of treatment with divalproex sodium vs. olanzapine on QoLLimitation – only 43% of randomized patients completed Q-LES-QRitsner et al., (2002) Israel 17 BD patients (9 manic, 4 depressed, 4 mixed)Q-LES-Q and LQOLP Q-LES-Q scores poorest in depressed patients, highest in manic.Limitation – small sample of patients diagnosed with BD.Robb et al., (1997)* Canada 68 euthymic BD patients (55 type I, 13 type II)IIRS Greater illness intrusiveness associated with higher Ham-D scores, recent depression and BD type II.Limitation – IIRS not validated for use in BD populations.Robb et al., (1998)* Canada 69 euthymic BD patients (54 type I, 15 type II)SF-20 Women possessed significantly lower SF-20 scores in the domains of pain and physical health.Limitation – shortcomings of SF-20 as a HRQOL measure.Russo et al., (1997) US 241 BD inpatients (138 depressed, 103 manic)QOLI Manic BD patients reported better QoL than BD depressed patients.Limitation – lower response rate in acutely manic group.Ruggeri et al., (2002) Italy 22 BD patients LQOLP LQOLP mean scores similar to those observed in larger mixed sample of psychiatric patients.Limitation – small sample of bipolar patients.Salyers et al., (2000) US 164 BD patients SF-12 Mental health scores significantly lower in patients with unipolar depression.Limitation – brief nature of SF-12.Shi et al., (2002) Europe US, South America South Africa453 BD patients, type I SF-36 Olanzapine superior to haloperidol in improving HRQOL during acute and continuation treatment in most SF-36 domains.Limitation – relatively high drop-out rates during acute treatment phase.Shi et al., (2004) 7 countries 573 BD in/outpatients, type I, most recent episode depressedSF-36, QLDS Olanzapine-fluoxetine combination associated with grater improvement in HRQOL.Limitation – high drop-out rate for an 8-week trial (55%).ten Have et al., (2002) Netherlands 136 BD patients (93 type I, 43 NOS)SF-36 BD sample generally showed greater impairment in SF-36 scores than patients with other psychiatric diagnoses.Limitation – accuracy of CIDI diagnosis of BD NOS in question.Tsevat et al., (2000) US 53 BD patients SF-36, TTO and SG TTO (0.61) and SG (0.70) scores for mental health comparable to those reported for other psychiatric conditions.Limitation – cognitive complexity of TTO and SG tasks.Vojta et al., (2001) US 86 BD patients (16 manic/hypomanic, 26 MDD, 14 mixed, 30 euthymic)SF-12 and EuroQoL SF-12 mental health scores significantly lower in manic group than in euthymic group. MDD/mixed group SF-12 scores significantly poorer than in manic/euthymic groups.Limitation – small sub-samples, brief nature of Table 1: Summary of studies assessing quality of life in patients with bipolar disorder (Continued)Page 5 of 17(page number not for citation purposes)the SF-12.CDSR (Cochrane Database of Systematic Reviews) (-2004)CCTR (Cochrane Controlled Trials Register) (-2004)DARE (Database of Abstracts of Reviews of Effectiveness)IPA (International Pharmaceutical Abstracts) (1965–2004)Key words used for the search included: bipolar disorderor manic-depression, mania, bipolar depression, bipolarspectrum and variants AND quality of life, health-relatedQoL, functional status, well-being and variants. Articleswere included if they were published in the English lan-guage, and reported on the assessment of generic orHRQOL in patients with BD. Our definition of QoL wasnot overly-inclusive; we required that studies had used aQoL or HRQOL scale that assessed several domains offunctioning. Studies using scales that examined singledomains of QoL (for example, those assessing solelysocial or occupational functioning, or single-item scalessuch as the GAF) were excluded. We omitted studies thatincluded fewer than 10 patients with BD, but did notreject reports for other scientific limitations (for example,convenience sampling or cross-sectional designs). Studiesthat were underway but were not completed wereexcluded, as were conference abstracts, dissertations orreviewed journals. We also excluded studies that reportedassessments in groups of patients with heterogeneousdiagnoses where results for patients with BD were notreported separately, and where individual results this pop-ulation could not be provided by the authors after per-sonal communication (for example, [11-25].ResultsThe results of the literature search are summarizedQUOROM-style in Figure 1. The final 28 included articlesare summarized in Table 1.Review of studiesThis section will review the 28 studies we identified. Forease of interpretation they are classified into the followingfour categories, although several studies met criteria formore than one category.i) Assessment of QoL in patients with BD at differentstages of the disorderii) Comparisons of QoL in patients with BD with that ofother patient populationsiii) QoL instrument evaluation in patients with BDiv) Treatment studies using QoL instruments to assess out-come in patients with BDHealth and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Wells et al., (1999) US 331 BD patients 944 double depression 3479 MDD 151 dysthymia 987 depressive symptomsSF-12, TTO and SG BD group had lower health utility than MDD, dysthymia and depressive symptoms groups.Limitation – cognitive complexity of TTO and SG tasks.Yatham et al., (2004) 15 countries 920 BD type I patients (currently depressed/experienced episode of depression in previous 60 days)SF-36 SF-36 scores markedly impaired compared to general population norms and consistently lower than sub-scale scores for patients with unipolar MDD.Limitation – depression severity not controlled for.* counted as one study for purposes of reviewEuroQoL visual analog scaleIllness Intrusiveness Rating ScaleLancashire Quality of Life ProfileLehman Quality of Life InterviewLongitudinal Interval Follow-up EvaluationMental Health Index 17MOS Cognitive Function ScaleMOS Short Form 12MOS Short Form 20MOS Short Form 36Occupational Performance QuestionnaireQuality of Life Enjoyment and Satisfaction QuestionnaireQuality of Life in Depression ScaleQuality of Life IndexQuality of Life InterviewSevere Mental IllnessStandard gambleTime tradeoffWorld Health Organization Quality of Life AssessmentTable 1: Summary of studies assessing quality of life in patients with bipolar disorder (Continued)Page 6 of 17(page number not for citation purposes)reports on QoL in BD that were not published in peer-Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72i) Assessment of QoL in patients with BD at different stages of the disorderWe identified ten studies of QoL in patients with BD atdifferent stages of the disorder. Four of these were gener-ated by a research group in Canada, and will be dealt within unison. Following this, six other studies (one compar-ing QoL in patients with during different phases of thedisorder, a recent study assessing QoL in bipolar depres-sion, one performed in a Turkish sample of interepisodepatients, one conducted in a sample of patients attendinga mental health service in Italy, one in recently dischargedpatients in Nigeria and a report on patients enrolled in theSTEP-BD Program) will be described.A research group in Toronto, Canada has generated aseries of interrelated reports on QoL in BD. Three of theseries [26-28] describe various aspects of QoL in a singlesample of outpatients (N = ~68) with BD type I (withmanic episodes) or II (with hypomanic episodes) whohad been clinically euthymic for at least one month (thesehave been counted as one study for the purposes of thisreview). Three of the series report on QoL in other patientpopulations [29-31]. Cooke and colleagues [26] exam-ined levels of HRQOL using the MOS SF-20, [32] a self-report questionnaire designed to assess perceived well-being in six domains (physical, social and role function-ing, mental health status, health perceptions and bodilypain). Mean scores on the SF-20 domains in studypatients were comparable to those reported for patientswith MDD by Wells and colleagues in the large RANDCorporation MOS Study [33]. Analysis of SF-20 scores bytype of BD showed that patients with BD type II reportedsignificantly poorer HRQOL than BD type I in the areas ofsocial functioning and mental health. In another paper,Robb and colleagues [27] reported on functioning in thecontext of the 'Illness Intrusiveness Model' in patientswith BD [34,35]. The model addresses the impact a disor-der and/or its treatment has upon an individual's activi-ties across 13 life domains: health, diet, active/passiverecreation, work/financial status, self expression/improve-ment, family relations, relations with spouse, sex life,other relationships, religious expression and communityinvolvement. The Illness Intrusiveness Rating Scale (IIRS)is used to yield a 'total illness intrusiveness' (TII) score. Ill-ness intrusiveness occurred in several areas of functioning,with TII being associated with higher Hamilton Depres-sion Rating Scale (Ham-D) scores, patients having experi-enced a recent episode of depression and having type IIBD. Robb and colleagues [28] specifically focused upongender differences in SF-20 scores, finding that womenpossessed numerically lower scores in all of the question-naire's domains except for mental health, with significantdifferences in the domains of pain and physical health.rated Global Assessment of Functioning or GAF scores)were not significantly different by gender.MacQueen and colleagues [29] examined SF-20 scores ineuthymic BD type I patients (N = 62) with or without psy-chotic symptoms during an index episode of mania. Nosignificant differences in SF-20 scores were apparentbetween patients with or without psychosis, although thesample identified with psychosis may have been too small(N = 16) to detect statistically significant differencesbetween sub-groups. Kusznir and colleagues [30] assessedlevels of community functioning via the OccupationalPerformance Questionnaire (OPQ) in a similar popula-tion, finding that one-third of patients did not meet crite-ria for adequate functioning on the 'CommunityFunctioning Scale' component of the questionnaire.Finally, MacQueen and colleagues [31] focused upon theeffect of number of manic and depressive episodes on SF-20 and GAF scores in euthymic patients (N = 64), findingthat number of past episodes of depression was a strongerdeterminant of HRQOL than number of previous manicepisodes. Good correlation between the subjectively ratedSF-20 and objectively rated GAF scores provided some evi-dence that euthymic patients with BD are capable of pro-viding accurate descriptions of their HRQOL.A potential advantage of this series of studies is that themajority of them were conducted in euthymic outpa-tients; interepisode patients are likely to be less prone tothe effects of cognitive distortion than are symptomaticpatients. However, euthymic patients are not necessarilyasymptomatic as many have mild sub-syndromal symp-toms, and several studies in this review will demonstratethat even residual depressive symptoms can be stronglyassociated with impaired QoL. The relationship betweenQoL and hypo/mania is less well understood. Both maniaand hypomania can be associated with substantial depres-sive symptomatology, either in the form of 'dysphoricmania/hypomania' or when the patient experiences amixed episode. This understanding led Vojta and col-leagues to hypothesize that patients with manic symp-toms would report significantly lower QoL than wouldpatients who were euthymic [36]. To test this theory, theauthors administered two brief self-report measures (theSF-12 and the EuroQoL visual analog scale) in bipolarpatients with mania/hypomania (N = 16), MDD (N = 26),mixed mania/hypomania and depression (N = 14) or whowere euthymic (N = 30). In keeping with their hypothesis,patients with mania/hypomania did show significantlylower SF-12 mental health scores than euthymic patients,with depressed or mixed patients showing significantlypoorer HRQOL again. Mean EuroQoL scores ran in thesame direction, although the difference between euthymicPage 7 of 17(page number not for citation purposes)Interestingly, objective measures of functioning (clinician and manic/hypomanic patients was not significant.Health and Quality of Life Outcomes 2005, 3:72http://www.hqlo.com/content/3/1/72Page 8 of 17(page number not for citation purposes)Table 2: Summary of studies using the SF-36 to assess quality of life in patients with bipolar disorder1Study Patient population Physical Social Role physicalRole emotionalPain Mental healthGeneral healthVitalityArnold (2000) 44 BD outpatients 78.8 ± 22.4 57.9 ± 27.7 63.1 ± 41.6 38.6 ± 43.1 64.9 ± 25.7 55.3 ± 23.8 61.9 ± 25.4 43.6 ± 24.3Have (2002)2 93 BD type I43 BD NOS89.691.273.680.877.681.769.580.674.182.562.368.762.668.258.062.0Leidy (1998) 34 euthymic28 depressed84.4 ± 20.272.2 ± 28.373.2 ± 18.229.3 ± 20.086.2 ± 28.032.3 ± 38.676.2 ± 31.28.3 ± 20.359.6 ± 29.054.7 ± 25.369.2 ± 17.933.4 ± 16.570.9 ± 20.758.0 ± 21.252.0 ± 16.220.4 ± 17.5Namjoshi (2002) 122 BD type I (manic/mixed) 65 olanzapine 57 placebo86.8 ± 16.884.5 ± 21.947.1 ± 28.346.0 ± 31.870.4 ± 40.265.4 ± 40.337.4 ± 42.336.3 ± 43.368.4 ± 26.461.7 ± 25.059.9 ± 22.658.5 ± 19.869.0 ± 22.765.2 ± 24.363.3 ± 24.066.6 ± 20.0Patelis-Siotis (2001) 34 BD CBT completers8 BD CBT non-completers80.4 ± 19.363.8 ± 30.658.1 ± 25.046.9 ± 28.141.2 ± 39.840.6 ± 44.217.6 ± 33.129.2 ± 41.568.5 ± 23.763.4 ± 27.052.4 ± 18.044.0 ± 22.066.6 ± 21.746.4 ± 29.639.4 ± 19.328.1 ± 21.4Revicki (1997) 14 BD patients (in-person)14 BD patients (by telephone)78.4 ± 25.277.0 ± 29.353.6 ± 30.257.1 ± 29.965.2 ± 38.759.8 ± 41.040.5 ± 42.933.3 ± 40.668.0 ± 31.869.3 ± 28.253.4 ± 22.853.9 ± 20.059.8 ± 22.857.5 ± 22.741.4 ± 18.741.4 ± 20.5Tsevat (2000) 53 BD patients 78.7 ± 23.4 58.7 ± 27.9 63.2 ± 40.9 38.9 ± 42.3 65.3 ± 26.0 56.2 ± 23.7 62.1 ± 24.3 45.4 ± 24.4Shi (2002) 453 BD type I234 olanzapine 219 haloperidol85.2 ± 23.290.5 ± 15.761.1 ± 31.861.2 ± 29.166.1 ± 39.672.8 ± 36.353.3 ± 43.150.1 ± 43.779.8 ± 26.281.2 ± 26.171.0 ± 20.472.8 ± 16.573.6 ± 21.875.1 ± 19.275.8 ± 19.180.0 ± 14.9Shi (2004) 573 BD type I (currently depressed)250 olanzapine58 olanzapine/fluoxetine combination265 placebo65.8 ± 27.668.8 ± 25.066.6 ± 26.229.1 ± 20.930.6 ± 20.832.5 ± 21.447.8 ± 44.044.8 ± 41.846.4 ± 42.312.9 ± 25.49.8 ± 23.414.6 ± 28.760.6 ± 27.160.8 ± 25.657.8 ± 26.130.0 ± 16.131.0 ± 17.331.3 ± 15.751.1 ± 22.352.3 ± 20.748.6 ± 22.625.5 ± 17.525.3 ± 19.025.6 ± 17.6Yatham (2004) 920 BD type I (currently depressed/ depressive episode in previous 60 days)70.2 ± 26.2 29.9 ± 22.8 36.7 ± 40.9 11.4 ± 23.5 62.2 ± 27.1 31.0 ± 17.3 47.5 ± 23.3 22.4 ± 17.71 Data presented as mean ± SD2 SDs not availableHealth and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72In the largest study to date of QoL in bipolar depression,Yatham and colleagues have reported on SF-36 scores inBD type I patients (N = 920) who were either currentlydepressed, or had experienced a recent episode of depres-sion [37]. SF-36 scores were remarkably low in the role-physical, vitality, social functioning, role-emotional andmental health sub-scales (see Table 2). The authors wenton to compare these scores with those derived from sevenlarge (>100 outpatients) studies of HRQOL in unipolardepression that had also administered the SF-36. Sub-scale scores tended to be lower in the bipolar sample thanin the unipolar sample, with the exception of the bodilypain sub-scale, where unipolar depressives tended toexhibit higher scores. Mean SF-36 scores were significantly(weakly: range -0.1 to -0.3) negatively correlated withHAM-D scores, providing some evidence for the constructvalidity of the instrument in this population. Whilst thisstudy is robust in terms of its large sample size and well-described clinical population, it did not control fordepression severity or demographic variables in between-group comparisons. Furthermore, diagnosis of bipolardisorder was made by careful clinical interview, whereasunipolar depression was diagnosed via a number of sub-jective and objective methods.A study by Ozer and colleagues [38] assessed 100 interep-isode patients with BD in Turkey with the aim of examin-ing the impact of 'history of illness' and 'presentsymptomatology' factors upon a variety of outcome meas-ures including the Schedule for Affective Disorder andSchizophrenia (SADS) and Quality of Life Enjoyment andSatisfaction Questionnaire (Q-LES-Q) [39]. The Q-LES-Qis a 93-item self-report measure of the degree of enjoy-ment and satisfaction in various areas of daily living. Thequestionnaire was developed and validated for use indepressed outpatients and has eight summary scales thatreflect major areas of functioning: physical health, mood,leisure time activities, social relationships, general activi-ties, work, household duties and school/coursework.Mean Q-LES-Q scores can be derived from the eight sum-mary scales and range from 0–100, where higher scoresindicate better QoL. Using multivariate analysis, Ozer andcolleagues found that none of the historical variables(including age at first episode, number of previous depres-sive/manic episodes, duration of illness, number of hospi-talizations, age at first hospitalization, or number ofsymptoms during first episode) were predictive of meanQ-LES-Q scores. Of the current symptoms assessed, onlythe depression subscale of the SADS interview signifi-cantly predicted lower Q-LES-Q scores, accounting foronly 13% of the observed variance. When the patient pop-ulation was subdivided into three groups (low, moderateand high) according to severity of SADS depression scores,reported to be 42% in hospitalized psychiatric inpatients[40], 42% in outpatients with MDD [41], 44% in patientswith seasonal affective disorder (SAD) [41], 53% inpatients with chronic MDD [42], and 83% in the generalpopulation (Rapaport, personal communication).Ruggeri and colleagues [43] investigated the relationshipbetween QoL and a variety of clinical and demographicvariables in a community-based sample of patients (N =268) with mixed psychiatric diagnoses, 22 of whom werebipolar. QoL was assessed via the Lancashire Quality ofLife Profile (LQOLP), which assesses perceived well-beingand functioning in 9 major life domains on a 7-point Lik-ert scale (where higher scores indicate better QoL). Weextracted LQOLP results for the bipolar sample from dataprovided by the authors, finding that mean satisfactionscores for the 9 domains were 4.4 ± 1.0, a score similar tothat reported for the entire patient sample. In anotherstudy of recently discharged Nigerian outpatients (N = 25)with BD type I or II, World Health Organization Qualityof Life Assessment (WHO-QOL-BREF-TR) scores werereported to be 'good' in 5 (20%) of patients, 'fair/average'in 14 (56%) and 'poor' in 6 (24%) of patients (data byWHOQOL-Bref domain also provided by authors duringpersonal communication) [44].Finally, Perlis and colleagues have recently provided ananalysis of 'early onset' in 983 patients (BD type I, II orNOS) enrolled in the Systematic Treatment EnhancementProgram for Bipolar Disorder (STEP-BD) [45] in whichQoL was assessed. The multicentre STEP-BD program, alarge prospective, naturalistic study than combines severalrandomized-controlled trials, has selected to use the Q-LES-Q to assess QoL and the GAF and 'Range of ImpairedFunctioning Tool' (LIFE-RIFT) to measure functional sta-tus. Perlis and colleagues provide the first report on QoLfrom the project, having looked specifically at the effect ofage of onset (grouped into 'very early age, <13 years', 'earlyage, 13–18 years' and 'adult, > 18 years') of mood symp-toms in BD upon outcome. Younger age of onset wasfound to be a significant predictor of Q-LES-Q scores atstudy entry (where treatment and clinical status wouldhave varied widely between patients), but not of function-ing as measured by the GAF or LIFE-RIFT. These resultsrepresent early data from a study that has the potential toaddress several important questions surrounding QoL inBD.ii) Comparisons of QoL in patients with BD with that of other patient populationsWe identified five studies comparing QoL betweenpatients with BD and patients with other conditions. Twoof these used the SF-36, one used the 'Quality of LifePage 9 of 17(page number not for citation purposes)mean Q-LES-Q scores were 39%, 38% and 35%, respec-tively. In comparison, mean Q-LES-Q scores have beenIndex', the Q-LES-Q and the WHO-QOL-BREF and oneapplied a 'health utilities' model.Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72The SF-36 [46] is currently the most widely used measureof HRQOL [47]. The self-report questionnaire containseight sub-scales assessing physical functioning, socialfunctioning, role limitations (physical), role limitations(emotional), pain, mental health, general health andvitality. These yield an overall domain score on a 0–100scale, where 0 represents worst possible health and 100best possible health. Arnold and colleagues [48] com-pared SF-36 scores between patients with BD (N = 44) andchronic back pain (N = 30) with norms previouslyreported for a general population sample (N = 2,474)[49]. The results of the study indicated that HRQOL wascompromised in all SF-36 domains except physical func-tioning in patients with BD compared with the generalpopulation sample (see Table 2). The BD group fared bet-ter than the back pain group in the physical, role limita-tion (physical), pain and social domains, although nosignificant differences were observed in terms of role lim-itation (emotional) or mental health domains. While thestudy provides a useful initial comparison of HRQOLbetween BD and other conditions, its findings should beinterpreted with some caution owing to the disparatesample sizes involved. It also utilized previously pub-lished norms for the SF-36 that had been derived by dif-ferent data collection methods.The Netherlands Mental Health Survey and IncidenceStudy (NEMESIS) has examined the epidemiology of psy-chiatric disorders in a large general population sample[50]. Using the Composite International Diagnostic Inter-view (CIDI), 136 adults were identified with DSM-III-Rlifetime BD (93 with BD type I and 43 with BD NOS) andadministered the SF-36. Participants with BD showed sig-nificantly more impairment in most of the question-naire's domains compared with NEMESIS subjectsdiagnosed with other psychiatric disorders (SF-36 scoresfor the BD group are presented in Table 2). For example,in the domain of mental health, participants with BD typeI experienced significantly lower mean scores (62.3) thanpeople with other mood (75.2), anxiety (74.0), substanceuse (80.2) or no psychiatric disorders (85.8). BD type Isubjects also experienced significantly lower SF-36 scoresthan patients with BD NOS in the domains of mentalhealth, role limitations (emotional), social functioningand pain. However, there remains some controversyabout the accuracy with which the CIDI detects BD NOS,limiting somewhat the inferences that can be made on thebasis of these sub-group results. A later analysis of a sub-set (N = 40) of the original NEMESIS sample administeredthe EuroQol: 5 Dimensions (EQ-5D) scale, which can beused to provide health utility values [51]. Mean utility val-ues (see below) for the sample were reported to be 0.82 ±0.20, comparable to those observed in the general popu-Atkinson and colleagues [52] used a different measure,the 'Quality of Life Index' [53], to assess QoL in patientswith BD (N = 37), MDD (N = 35) or schizophrenia (N =69). The authors found that subjectively reported QoLwas lower in patients with BD and MDD than in thosewith schizophrenia. Interestingly, this trend was reversedfor objectively assessed QoL, which included measuressuch as medical history, health risk behaviors, educationaland financial levels and social functioning. These findingsled the authors to speculate about the validity of subjec-tive measures of QoL, particularly in people with affectivedisorders. These results were not replicated in Indian byChand and colleagues, who compared the QoL of patientswith BD (in remission and stabilized on lithium prophy-laxis, N = 50) with patients with schizophrenia (N = 20)and healthy controls (N = 20) [54]. Using the Q-LES-Qand the WHOQOL-BREF, the authors found that thebipolar group reported significantly better QoL than theschizophrenia group in all domains of the Q-LES-Q, andin general well-being, physical health and psychologicalhealth on the WHO scale. Surprisingly, the authors alsoobserved that perceived QoL was equivalent betweenpatients with BD and healthy controls, with the exceptionof the Q-LES-Q leisure domain, where the patient groupactually reported better functioning. Having said this,mean Q-LES-Q scores for this particular control groupwere unusually low (approximately 47%, where generalpopulation norms for the United States are around 83%,Rapaport, personal communication).Although a growing number of studies have now evalu-ated the 'health utilities' and 'health preferences' ofpatients with physical conditions, relatively few haveexamined these values in patients with mental illnesses,including BD. The concept of health utility refers to anindividual's preferences for different health states underconditions of uncertainty. Health preferences are valuesthat reflect an individual's level of subjective satisfaction,distress or desirability associated with various health con-ditions. Health utility and preferences are frequentlyassessed by the 'time tradeoff' (TTO) and 'standard gam-ble' (SG) approaches [55]. TTO refers to the years of life aperson is willing to exchange for perfect health. For exam-ple, patients might be asked to imagine that a treatmentexists that would allow them to live in perfect physicaland mental health, but reduces their life expectancy. Theymight then be asked to indicate how much time theywould give up for a treatment that would permit them tolive in perfect health, if they had ten years to live. SG refersto the required chance for successful outcome to accept atreatment that could result in either immediate death orperfect health. For example, patients might be asked toimagine that they had ten years to live in their current statePage 10 of 17(page number not for citation purposes)lation of the Netherlands. of health, and that a treatment existed that could eithergive them perfect health, or kill them immediately.Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Patients might then be asked to indicate what chance ofsuccess the treatment would have to have before theywould accept it. Health utility and preference values arefrequently expressed as a score of 0 to 1, with higher val-ues representing better health.We identified one study comparing health utility inpatients with BD with other patient populations. Wellsand colleagues (1999) [56] assessed functioning and util-ity in patients with depression or chronic medical condi-tions within seven managed care organizations in theUnited States. HRQOL was assessed via the global mentaland physical scales of the SF-12 and utility was measuredvia TTO and SG. Patients with depression were catego-rized as those with BD (N = 331), 12-month MDD (N =3479), 12-month double depression (N = 944), 12-month dysthymia (N = 151) or brief subthreshold depres-sive symptoms (N = 987). In terms of HRQOL, the bipolargroup showed levels of impairment second only topatients with double depression. Utility was also lower inthe bipolar group compared with patients with MDD, dys-thymia or brief depressive symptoms, although not dou-ble depression. In terms of health utility, bipolar patientswere willing to give up on average 17% of their life expect-ancy in return for perfect health, and would accept onaverage an 11% risk of death in exchange for perfecthealth. In comparison, patients with MDD were willing togive up 11% of their life expectancy, and accept a 6% riskof death.iii) QoL instrument evaluation in patients with BDWe identified five studies that had evaluated differentQoL instruments in BD populations and one study thatexamined the effects of mode of questionnaire adminis-tration. The first of these examined the application of theaforementioned health utility approach. The secondassessed the psychometric properties of the Lehman Qual-ify of Life Interview (QOLI) in a heterogeneous sample ofpsychiatric inpatients. The third evaluated four QoL scalesin a smaller sample of Patients with BD, while the fourthassessed the MOS SF-12 in a large population of patientswith severe mental illness. The fifth study evaluated theproperties of the Q-LES-Q and the LQOLP in a sample ofIsraeli patients with severe mental disorders. The finalstudy we identified examined telephone versus in-personhealth status assessment in outpatients with BD.Tsevat and colleagues (2000) [57] examined functionalstatus and health utility in 53 outpatients with BDrecruited from one site of the multicenter Stanley Founda-tion Bipolar Network study. The authors aimed to assesshow patients with BD rated their current overall healthversus their current mental health, and to determine thesignificantly higher than scores for current mental health,which averaged 0.61. In other words, patients with BDwere willing to give up on average 39% of their life expect-ancy in return for perfect mental health. These values aresimilar to TTO values obtained in the Beaver Dam HealthOutcomes Study in patients with depression (0.70) oranxiety (0.77). SG scores were not significantly differentfor overall health (0.77) and mental health (0.70). SF-36scores for the study are presented in Table 2. Certain SF-36domains (general health, vitality and role-emotional)were significantly correlated with mental health TTO andSG scores, but levels of mania were not correlated withutilities for either overall health or mental health. Theauthors concluded that health utilities may be related tocertain health status attributes and to level of depression,but may not be related to level of mania in patients withBD. One advantage of the health utility/preferenceapproach to QoL assessment is that it allows the calcula-tion of quality-adjusted life years (QALYs). QALYs are acommonly used outcome measure in cost-effectivenessstudies, but our literature search did not find any studiesthat had calculated QALYs for BD populations.Russo and colleagues [58] performed a rigorous psycho-metric evaluation of the QOLI [59] in a large sample (N =981) of acutely ill hospitalized psychiatric inpatients. Ofthese, 138 were diagnosed according to DSM-III-R criteriawith bipolar depression, 103 with acute mania and theremainder with unipolar depression, schizophrenia, or'other' diagnoses. The QOLI contains 44 items and 7 sat-isfaction scales, a global satisfaction item and 14 func-tional items, with all satisfaction scores ranging from 1(terrible) to 7 (delighted). Patients were administered theinstrument using a structured interview procedure within48 hours of admission and discharge. While the QOLI wassuccessfully completed by 90% of patients overall, ratesdid vary according to patient diagnoses with non-comple-tion rates being lowest in patients with bipolar depression(12%) and highest in manic patients (31%). Reasonsgiven for non-completion of the measure varied, the mostcommon being 'inadequate staff time' (39%), 'patient toopsychotic, demented, or confused' (13%), or 'too agitatedor sleepy' (12%). The QOLI showed good psychometricproperties overall, although there was some concernabout an apparent lack of construct consistency (low cor-relations between satisfaction and functional measures)in patients with mania. Analysis of QOLI sub-scalesshowed that, broadly speaking, manic patients reportedthe highest levels of satisfaction and function, with bipo-lar and unipolar depressed patients reporting the lowestlevels.Leidy and colleagues [60] examined the psychometricPage 11 of 17(page number not for citation purposes)extent to which health utility correlated with disease state.TTO scores for current overall health were 0.71, but wereproperties of four QoL measures in 62 BD type I patients(34 euthymic, 28 depressed). Patients completed the SF-Health and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/7236, the Quality of Life in Depression Scale (QLDS), theMental Health Index 17 (MHI-17) and the MOS CognitiveFunction Scale (CFS). The study provided further evidencethat both euthymic and depressed patients with BD arecapable of providing subjective reports of their HRQOL.Baseline SF-36 scores were markedly impaired in thedepressed sub-group, with the vitality, social and role lim-itation (emotional) domains all falling below the 25thpercentile (see Table 2). QoL as measured by the QLDSwas poorer than has been reported elsewhere for patientswith unipolar depression. Cronbach's alpha scores for theQLDS, MHI-17, CFS and four of the eight SF-36 sub-scales(physical functioning, role physical, vitality and metalhealth) all fell above the generally accepted level of 0.80.Test-retest reliability for the scales were modest (intraclasscorrelations ranged between 0.18 on the SF-36 role emo-tional scale and 0.80 for physical functioning), althoughthe reliability of the scales was assessed over an unusuallylong time period (8 weeks). Scores on the QLDS, MHI-17and CFS were significantly correlated with patients' Ham-D scores, as were several of the SF-36 sub-scales, thus con-firming the construct validity of the scales in patients withBD. Finally, the MHI-17, CFS, QLDS and SF-36 vitality,role emotional and mental health sub-scales were shownto be responsive to change in depression status over time;the QLDS has recently been successfully used as an out-come measure in a large pharmaceutical treatment trial(Shi et al., 2004, see section IV).Salyers and colleagues [61] conducted a psychometricevaluation of another MOS instrument, the SF-12 [62], ina sample of 946 patients with severe mental illness, 164 ofwhom were diagnosed with BD. Mean (± SD) SF-12 phys-ical functioning and mental functioning scores for thebipolar group were 46.1 ± 11.5 and 39.6 ± 12.7 respec-tively, although mental health functioning scores weresignificantly lower (31.8 ± 13.4) in patients with unipolarMDD. The instrument showed acceptable levels of relia-bility and validity in the entire sample, although it isworth noting that is was administered by trained inter-viewers, rather than as a self-report measure.Ritsner and colleagues [63,64] have compared responseson the Q-LES-Q and the LQOLP in a sample of 175 non-clinical controls and 199 Israeli patients with severe men-tal illness (SMI), 17 of whom were diagnosed with BD. Inpersonal communication with the authors, we wereinformed that mean Q-LES-Q scores for the manic,depressed and mixed sub-groups of Patients with BD inthe study were 40%, 25% and 33% respectively. Bothinstruments showed generally acceptable levels of internalconsistency, test-retest reliability and criterion validity (inthe entire patient population) but notably low levels ofleagues (1997) [65] examined the effects of administeringthe SF-36 either in person or by telephone in 28 patientswith BD (see Table 2). SF-36 domain scores were not sig-nificantly affected by mode of administration.iv) Studies using QoL instruments to assess outcome in patients with BDWe identified eight studies that had used a QoL measureto assess outcome in BD populations: five clinical trialsthat examined pharmacological interventions for the dis-order and three studies that assessed non-pharmacologi-cal interventions.Namjoshi and colleagues from a Lilly research group haveconducted a series of studies examining the impact oftreatment with olanzapine upon QoL [66-70]. In the first,Namjoshi et al., (2002) evaluated the impact of acute (3-week) treatment with olanzapine or placebo and long-term (49-week open label) treatment of BD type I (manic/mixed). Baseline SF-36 scores for the olanzapine and pla-cebo group are shown in Table 2. During acute-phasetreatment, a significant improvement was observed in thephysical functioning domain of the SF-36 in the olanzap-ine group. During the open label treatment period, how-ever, the SF-36 bodily pain, vitality, general health andsocial functioning domains showed significant improve-ments over time. This may indicate that olanzapine has arelatively rapid effect in terms of improving physical func-tioning in patients with acute mania, but that treatmentmay be required for longer periods for functioning toimprove in other QoL domains.Shi and colleagues have also compared the treatmenteffects of olanzapine and haloperidol in patients withacute mania (N = 453) [67,68] weeks of acute-phase treat-ment, significantly greater improvement in five of the SF-36 domains (general health, physical functioning, rolelimitations – physical, social functioning and vitality) wasapparent in the olanzapine group. Superiority of olanzap-ine over haloperidol persisted over the study's 6-weekcontinuation phase, with concomitant improvements inwork and household functioning. Baseline SF-36 scoresfor the olanzapine and haloperidol groups are shown inTable 2. A further study examined the effects of addingolanzapine to lithium or valproate in patients with BD (N= 224) [69]. Olanzapine cotherapy was associated withbetter outcome in several QOLI domains compared tomonotherapy with lithium or valproate alone. The SF-36and QLDS have been used in a study comparing the ben-efits of olanzapine alone versus an olanzapine-fluoxetinecombination or placebo [70]. Compared with placebo,patients who received olanzapine showed greaterimprovement at 8 weeks in SF-36 mental health summaryPage 12 of 17(page number not for citation purposes)convergent validity between the instruments' domains,particularly in the control group. Finally, Revicki and col-scores, and in mental health, role-emotional and socialfunctioning domain scores (SF-36 scores summarized inHealth and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72Table 2). The combination group fared significantly betterin terms of HRQOL improvement than the olanzapine-alone group, showing improvement in 5 of the SF-36domain scores and in QLDS total score. The authors alsoperformed a psychometric evaluation of the QLDS (seesection III).Finally, the Q-LES-Q has been administered at baseline(hospital discharge), 6 and 12 weeks in a comparison ofdivalproex sodium and olanzapine in the treatment ofacute mania [71]. No significant treatment effects weredetected in Q-LES-Q scores in the study, although only 52(43%) of the 120 patients randomized to either dival-proex or olanzapine completed the QoL instrument.Interestingly, the authors reported an association betweenweight gain being reported as an adverse event and poorerchange scores in the physical, leisure, and general activi-ties domains of the Q-LES-Q at 6 weeks (but not at 12weeks). Negative correlations were reported betweenincreased weight (at 6 weeks) and overall life satisfaction,physical health, mood, general activities and satisfactionwith medication on the Q-LES-Q.Although current recommendations favor the use of phar-macological treatments such as lithium and mood stabi-lizers in the initial treatment and symptom control of BD,there is increasing recognition of the role of psychother-apy in the management of the disorder. We identified onestudy that had used a QoL tool to assess outcome follow-ing a psychotherapy intervention for BD. Patelis-Siotisand colleagues [72] used the SF-36 in a feasibility study ofgroup cognitive behavior therapy (CBT) in patients withBD. Although baseline SF-36 data was available for 42patients (see Table 2), pre and post intervention data wasonly available for a proportion of participants (N = 22) ascompletion of the QoL questionnaires was optional. Nev-ertheless, SF-36 vitality and role emotional scores weresignificantly improved following CBT, with an accompa-nying trend towards improved social functioning.Another study we identified specifically examined theeffects of vocational rehabilitation upon outcome in 149patients with SMI, 21 of whom were diagnosed with bipo-lar disorder [73]. In personal communication with theauthors, we learned that mean (± SD, range 1–7 wherehigher scores indicate better QoL) baseline QOLI 'overalllife satisfaction' scores were 4.7 ± 1.1, with 'general satis-faction' domain scores of 4.9 ± 1.3. Although outcomedata was not available specifically for the bipolar group,better QoL outcomes were associated with 'competitivework activity' in the overall sample compared to otherreduced forms of work activity. Finally, a recent study hasexamined the effects of providing 3 sessions of psychoed-ucation about lithium treatment to patients (N = 26) withined the impact of education upon QoL, as measured bythe WHO-QOL-BREF. Following psychoeducation,patients in the intervention arm of the study showed sig-nificant improvement in 2 of the WHOQOL BREF's 4domains (physical health and social functioning) and inoverall perceived health. Patients in the control arm of thestudy, in comparison, showed no significant changes intheir perceived QoL. The results of the study indicate thatit may be possible to alter patients' perceptions of theirQoL even with relatively brief psychological interven-tions.DiscussionPrior to 1999, only 10 studies had systematicallyaddressed the measurement of HRQOL in patients withbipolar disorder [10]. A second review of studies that hadexamined HRQOL in BD prior to 2004 identified 65 stud-ies [9]. We conducted a subsequent review of studiesexamining generic and HRQOL in bipolar disorder thathad been published prior to November 2004. Our litera-ture search identified 28 studies in total, 7 (25%) of whichwere published before 1999 (there is discrepancy in thenumber of studies identified prior to 1999 between thetwo reviews due to differing inclusion criteria). Theremaining 21 (75%) were published between 2000 and2004, indicating that there is developing interest in thisfield of research. The studies we identified were quite het-erogeneous in nature. Several undertook to assess QoLduring different phases of the disorder, for example, cross-sectional research that compared perceived QoL ineuthymic, manic or depressed patients with BD. Otherstudies compared QoL in bipolar samples to that of otherpatient populations, both with other psychiatric disordersand with chronic physical conditions. Another vein ofresearch examined the psychometric properties of a vari-ety of generic and HRQOL instruments in BD popula-tions. Finally, we identified several studies that had used aQoL instrument to assess outcome in trials of pharmaco-logical and non-pharmacological treatment inventionsfor the condition.The studies were also of variable scientific quality. Meth-odological shortcomings included small sample sizes,cross-sectional designs, idiosyncratic diagnostic methodsor undifferentiated diagnostic groups, and use of inappro-priate or poorly validated QoL instruments. This beingsaid, the overall scientific quality of research in this fielddoes appear to be improving. Of the 10 studies identifiedin the review by Namjoshi and colleagues, only one pos-sessed a sample of size of more than 100 patients with BD.In comparison, we identified eleven studies that hadenrolled more than 100 patients. It was particularlyencouraging to see that some of the large pharmacologicalPage 13 of 17(page number not for citation purposes)BD [74]. In addition to assessing the effects of psychoed-ucation upon medication adherence, the authors exam-trials of treatment interventions for BD are now using QoLmeasures as secondary outcome measures. Clinical trialsHealth and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72in bipolar populations have traditionally used objectivelyrated measures such as rates of relapse, hospitalization orsymptom reduction to assess patient outcome. However,the concomitant use of QoL indices does appear to paydividends. For example, Namjoshi and colleagues [66]found that the timing of response to treatment with olan-zapine differed in terms of symptomatic and QoL out-come. Symptom reduction in the olanzapine groupoccurred relatively quickly, with patients showing a 10-point decrease in Young Mania Rating Scale (YMRS)scores during the study's 3-week acute treatment phase.Improvements in SF-36 scores, however, occurred moreslowly. Only the domain of physical functioning showedsignificant improvement by the end of the acute treatmentphase, whereas it was the domains of social functioning,general health, vitality and bodily pain that were signifi-cantly improved at the end of the 49-week maintenancephase. These findings are in accordance with otherresearch showing that 98% of first episode mania patientsachieve syndromal recovery after 24 months, but only38% achieve functional recovery [75]. Sole reliance onsymptomatic outcome measures may not detect thesemore subtle changes in well-being, functioning and QoL.Although there appears to be increasing use of QoL meas-ures in pharmacological research in bipolar populations,we identified surprisingly few studies of psychologicalinterventions that had incorporated a QoL assessment. Ina review of psychosocial interventions for BD, Huxley andcolleagues (2000) [76] identified 32 peer-reviewedreports examining group, couple/family or individual psy-chotherapy in BD, none of which systematically assessedQoL. Our own review only identified one relevant publi-cation, a feasibility study of group CBT which incorpo-rated the SF-36 [72]. As Huxley and colleagues note,future research in this area should employ much broadermeasures of outcome, such as the assessment of QoL,which may be less amenable to pharmacological treat-ment in isolation.An important general conclusion from this review is thatthe measurement of QoL is feasible in some patients withBD. However, there remains a paucity of informationabout the ability of patients in the hypo/manic phase oftheir illness to reliably and accurately complete QoLmeasures. One of the more rigorous studies to date wasperformed by Russo and colleagues (1997) [58], in whichnurses administered the QOLI via a structured interviewprocedure to 103 patients with acute mania. Completionrates for the questionnaire were 69% in acutely manicpatients, compared to 88% in bipolar depressed patients.In the Namjoshi et al., [66] study of olanzapine inpatients with acute mania, SF-36 scores were successfullyVojta and colleagues [36], two brief QoL instruments weresuccessfully completed by 16 patients with mania/hypo-mania. More research is needed to ascertain how feasibleit is to administer self-report measures of QoL in patientswith hypo/mania, although other research in bipolar pop-ulations has indicated that patients with mild to moderatemanic symptoms can provide reliable descriptions of theirsymptoms [77]. Although there is controversy about thevalidity of the technique, [78] proxy measures of QoL canbe obtained from family members or clinicians, and mayoffer one solution to this problem. Additional research isalso needed to determine the longitudinal course of QoLin patients with BD. The majority of the studies we identi-fied were cross-sectional in nature. Useful future researchwould longitudinally follow the course of QoL in a cohortof patients with BD as they experienced different phases ofthe illness. Research is also required in first-episode maniapatients to help elucidate the relationship between lengthof illness, episode frequency and QoL.The studies we identified were also heterogeneous interms of the QoL instruments they incorporated. By farthe most frequently utilized were the MOS range ofHRQOL measures; 16 of the 28 studies we identified(57%) utilized the SF-12, SF-20 or the SF-36. The resultsof studies using the SF-36 were amalgamated in Table 2.Inspection of these data indicates that, in general, physicalfunctioning appears to be relatively good in patients withBD (range 63.8 – 91.2). Mental health scores are unsur-prisingly much lower (range 30.0 – 72.8). In comparison,SF-36 mental health functioning scores have beenreported to be 40.0 (± 17.5) in primary care patients (N =536) initiating treatment for depression [79]. However, itremains difficult to make any broad generalizations onthe basis of this grouped data owing to differences inpatient populations, recruitment methods and samplesizes that result in wide ranges of scores in some domains.Given the breadth of existing data for the SF-36 in bipolarpopulations, the scale's acceptable psychometric proper-ties and detailed normative data, we recommend thisscale for the measurement of health-related QoL inpatients with BD. The WHO-QOL-BREF is an alternativethat has undergone rigorous international developmentand is available in a wide variety of languages.A number of other QoL instruments have been utilized inbipolar populations, including the Illness IntrusivenessRating Scale (IIRS), the Quality of Life Enjoyment and Sat-isfaction Questionnaire (Q-LES-Q), the Lehman Qualityof Life Interview (QOLI), the WHO-QOL-BREF and thehealth utility time tradeoff (TTO) and standard gamble(SG) approaches. However, only a small number of thestudies we identified reported on the psychometric prop-Page 14 of 17(page number not for citation purposes)obtained for 122 of 139 (88%) of patients who enteredthe study's randomization phase. In the smaller study byerties of these instruments, and it remains the case thatfew measures of QoL have been appropriately evaluatedHealth and Quality of Life Outcomes 2005, 3:72 http://www.hqlo.com/content/3/1/72for use in BD populations. Some of these instruments aresemi disease-targeted in the sense that they have beendeveloped in and for depressed populations (i.e. the Q-LES-Q and QLDS). Both the Q-LES-Q and QLDS appear topossess acceptable psychometric properties and, impor-tantly, are responsive to change in response to both psy-chological and pharmacological treatment interventionsand can be recommended here for use in bipolar popula-tions.There is at present no QoL measure specifically designedfor use in bipolar populations. Although existing QoLinstruments are likely to capture key aspects of QoL, theymay be insensitive to some of the unique problems posedby this complex psychiatric condition. For example, fewQoL instruments designed for use in psychiatric popula-tions assess routine, independence, spirituality or stigma,which have been sown to have particular bearing uponQoL in patients with BD [80]. Bipolar disorder is alsounique in that it can be characterized by a variety of moodstates, including hypo/mania, depression or mixed states.The understanding that mania can also be associated withdepressive symptoms, and that patients will experienceperiods when they are relatively euthymic, complicatesthe assessment of QoL in this population. We suggest thatan important step forward in this field of research wouldbe made with the development of a disease-specific QoLinstrument for BD. We believe that such an instrumentwould need to have a number of qualities. It would haveto work effectively in the depressed, hypo/manic, mixedand euthymic phases of BD. It would need to be conciseenough not to put overdue response burden on thepatient, but detailed enough to tap into the major areas ofwell-being affected by the disorder. The relevance of thescale would need to be ensured by thorough consultationwith patients, their families and their clinicians. This proc-ess should involve individual qualitative interviews andfocus group work with patients with BD and their familymembers at different stages of the disorder, and consulta-tion with psychiatrists, mental health workers, and pub-lic-sector organizations. It would be useful if theinstrument was available in self-report, interviewer-administered and proxy-respondent formats to providealternative methods of administration in acutely manicpopulations. Finally, the psychometric properties of theinstrument would need to be carefully evaluated in termsof reliability, validity, responsiveness and other standardpsychometric assessments.ConclusionIn recent years, major developments in the pharmacolog-ical control of bipolar disorder have occurred. One resultof these improvements has been that some patients willcerns, including improving inter-episode functioning andperceived quality of life. Our review found that there isgrowing interest in characterizing QoL in bipolar disorderpopulations, and determining the impact of treatmentinterventions upon life quality. The scientific quality ofresearch in this field has been variable, but increasingnumbers of studies of good design are now being con-ducted. We highlighted several important avenues forfuture research, including the need for assessments of QoLin first episode and hypo/manic patients, more well-designed longitudinal research and research into theimpact of psychosocial interventions upon QoL, and thedevelopment of a disease-specific measure for use in bipo-lar populations. Bipolar disorder creates a major healthconcern, both for the individual and for society, and moreinformation is still needed about the impact of the condi-tion upon QoL. Such information may then bring us onestep closer towards developing treatment regimens thatmaximize both symptom reduction and quality of life forpatients with this complex condition.References1. The WHOQOL Group: The World Health Organization Qual-ity of Life Assessment (WHOQOL): Position Papaer Fromthe World Health Organization.  Social Science Medicine 1995,10:1403-1409.2. Patrick DL, Erickson P: Assessing health-related quality of lifefor clinical decision making.  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