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Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 733-738  

Patterns and correlates of mental disability in euthymic patients with bipolar affective disorder: A descriptive study

1 Department of Psychiatry, B. J. Government Medical College, Pune, Maharashtra, India
2 Department of Psychiatry, Post Graduate Institute YCMH, Maharashtra, India

Date of Submission27-Oct-2021
Date of Decision19-Feb-2022
Date of Acceptance21-Feb-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Avinash D Karde
402.B, Saakaralmond Park, Near Kumar Meadows, Solapur Road, Majri Bk, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_852_21

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Background: Substantial proportion of bipolar affective disorder (BPAD) patients are symptomatic more than half of their lives despite receiving pharmacological treatment leading to functional impairment and disability. Objectives: To study the correlation of disability with socio-demographic and clinical variables in euthymic patients with BPAD. Methods: A hospital-based cross-sectional study was conducted on 100 euthymic patients of BPAD using purposive sampling. Data were collected using semi-structured proforma and diagnostic categorization of patients was done according to ICD-10 research criteria, Hamilton's Rating Scale for Depression (HAM-D), and Young Mania Rating Scale (YMRS). Indian Disability Evaluation Assessment Scale (IDEAS) was administered for disability assessment. The variables were analyzed using appropriate tests, namely, analysis of variance (ANOVA) test, two independent sample t test, Fisher's exact test, and Spearman's correlation coefficient. Results: 81% patients of BPAD had a mild disability and 19% patients had a moderate disability. The total duration of illness score (mean 3.8) was the major determinant of disability on IDEAS. There was a statistically significant association of age (P < 0.001), gender (P = 0.027), subsyndromal manic features (P < 0.001), and number of previous episodes (P < 0.001) with disability, and there was no association of socioeconomic status, marital status, occupational status, duration of illness, age of onset, and number of previous hospitalizations with disability. Conclusion: Bipolar affective disorder is associated with mild-to-moderate disability on evaluation using IDEAS instrument. There is a need for further studies on the utility of IDEAS and its individual domains in the assessment of disability due to bipolar affective disorder.

Keywords: Bipolar disorder, disability, HAM-D, IDEAS, YMRS

How to cite this article:
Karde AD, Panse SN, Santre M. Patterns and correlates of mental disability in euthymic patients with bipolar affective disorder: A descriptive study. Med J DY Patil Vidyapeeth 2022;15:733-8

How to cite this URL:
Karde AD, Panse SN, Santre M. Patterns and correlates of mental disability in euthymic patients with bipolar affective disorder: A descriptive study. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2023 Jan 30];15:733-8. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/733/350686

  Introduction Top

Bipolar affective disorder (BPAD) is one of the most serious mental illnesses characterized by extreme alterations in mood, cognition, and behavior causing a significant negative impact on the functioning and quality of life of the affected individuals.[1],[2] According to the International Classification of Functioning, Disability, and Health (ICF), disability is a multidimensional concept, involving interference with activities of the whole person in relation to the immediate environment. It acknowledges disability as evolving dynamic and complex phenomenon.[3] Global Burden of Diseases (GBD) study 1990–2017 recognized that the consequences of mental disorders include not only mortality but also morbidity, and mental disorders were the second leading cause of Years Lived with Disability (YLDs) and sixth leading cause of Disability-adjusted Life years (DALYs) in world.

In India, the contribution of BPAD in terms of disability-adjusted life years (DALYs) was 6.9% (95% uncertainty interval 4.9–9.6).[4] BPAD patients commonly have functional impairment in family, social, and vocational or work domains.[5],[6],[7],[8] Functional outcome depends on sociodemographic and clinical factors such as age at onset,[1],[8],[9],[10] mood states,[7],[11] frequency of episodes,[8],[12] cycle pattern, psychotic symptoms,[12] population growth and aging,[6],[12] psychiatric comorbidity,[8],[9],[13] neurocognitive factors,[6],[14],[15] treatment compliance,[12] duration of illness,[11],[12],[15] and number of hospitalizations.[8],[13]

The poor functioning or the disability even in treated euthymic (non-symptomatic or symptomatic below the threshold of manic or depressive episode) or subsyndromal patients is one of the main factors that explains the high burden of disability in bipolar affective disorder patients (BPAD), which has been noted in the several studies.[2],[12] The previous systematic literature review has concluded that most of the researchers in the world preferred using Global Assessment of Functioning (GAF), Functional Assessment Short Test (FAST),[2],[14],[16] World Health Organization Disability Assessment Schedule I or II (WHO-DAS I or II), and 36- and 20 item Short Form Health Survey[5] scales to measure the functional outcome. However, in Indian context, Disability Task Force of Indian Psychiatric Society has recommended the use of Indian Disability Evaluation Assessment Scale (IDEAS) for the disability assessment of all mental illnesses, which is the modified version of WHO Disability Assessment Schedule (WHO-DAS 2.0).[17] Choudhury et al.[18] assessed disability using IDEAS in seven psychiatric disorders including BPAD and found that 30% patients with BPAD showed significant disability in the core domains of the functioning.

The current concept of well-being is not just to feel well but to do well, meaning that patients want a functional recovery in the domains of work and study, live independently, and engage in recreational activities and interpersonal relationships.[19] A recent review of literature highlights the importance of evaluation of the functional outcomes using domain-specific scales in patients of BPAD.[14],[16] Research work in the area of psychiatric disability has focused more in psychosis compared to BPAD.[19] Most of the studies are from western research literature and there are very few studies on BPAD related disability reported in the Indian context. The present study was contemplated with the objectives to study the pattern of disability in euthymic BPAD patients and to assess the correlation between socio-demographic and clinical variables with disability in euthymic BPAD patients using standard and validated instruments.

  Material and Methods Top

Study Design: A descriptive cross-sectional study was conducted in the Department of Psychiatry of a tertiary care referral hospital attached to a Government Medical College located in the western part of India.

Study subjects: The patients of BPAD attending psychiatric outpatient department were recruited for this study. The drainage population is from the same and neighboring districts comprising both urban and rural population from all socio-economic strata.


After the study protocol was approved by the Institutional Ethics Committee, 100 patients of BPAD attending psychiatric outpatient department were recruited over a one-year period for this study using purposive sampling with their written informed consent. Subjects in the age range of 18 to 65 years of both genders diagnosed as per ICD-10 criteria with illness duration more than 2 years currently in euthymic state without psychiatric co-morbidity, organic brain disease, or chronic debilitating illness were included. Socio-demographic and clinical details were recorded in the semi-structured proforma and diagnostic categorization was done according to ICD-10 research criteria.[20]

The current status of the BPAD was assessed using Hamilton's Rating Scale for Depression (HAM-D)[21] and Young Mania Rating Scale (YMRS).[22] There was no cut-off score used for the selection of patients, though a score of 6 or less on YMRS while a score of 8 or less on HAM-D typically characterizes an asymptomatic state. Socioeconomic status was assessed using Kuppuswamy's socioeconomic status scale.[23] Indian Disability Evaluation Assessment Scale (IDEAS) was administered for disability assessment. This scale was developed by the Rehabilitation Committee of Indian Psychiatric Society, in December 2000. It is recognized by the Ministry of Human Resources and Empowerment, Government of India.[24] It quantifies disability by relying on information in four core areas of self-care, interpersonal relationships, communication and understanding, and work functioning. The disability is graded over a 5-point scale: no disability (score 0), mild (score1–7), moderate (score 8–13), severe (score 14–19), and profound (score 20).

Statistical analysis

The results obtained were tabulated and statistical analysis was performed using Statistical Package for Social Sciences (SPSS) for Windows (version 20) and Microsoft Excel 2007. The variables were analyzed using the ANOVA test, 2 independent sample t test, Fisher's exact test, and the Spearman's correlation coefficient. Significance levels for all analyses were set at the P value less than 0.05.

  Results Top

Sociodemographic variables

The mean age of study sample was 44.22 years. Most of the patients were gainfully employed out of which 24% were salaried, 27% were farmers, 25% were laborers, 22% were homemakers, and only 2% were unemployed [Table 1].
Table 1: Correlation of sociodemographic variables with disability

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Clinical variables

There was no case of childhood-onset BPAD in the study sample. The distribution of number of episodes and previous hospitalizations is shown in [Table 2] in correlation with disability scores.
Table 2: Correlation of clinical variables with disability

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Correlation of variables with disability

It was observed that with increasing age mean IDEAS score increased, which was statistically significant (P < 0.001). There was a statistically significant correlation between gender and disability (P = 0.027) indicating that female patients of BPAD had more disability as compared to male patients [Table 1]. The Mean IDEAS score was comparable in married and single (Unmarried/divorced/separated) patients showing that both groups had similar disability. No significant correlation was noted between disability and marital status, urban domicile, religion, education, employment or socioeconomic status.

In our study, 81% of BPAD patients had a mild disability and 19% patients had a moderate disability as per IDEAS global score. On IDEAS individual domain score, “self-care” was the least affected domain with mean score of 0.22 (SD 0.43) and “interpersonal activities” was the most affected domain with mean score of 0.52 (SD 0.54). There was a statistically significant correlation noted between number of episodes and disability (P < 0.001). 12% patients had YMRS score >=6 indicating subsyndromal manic symptoms, which showed a statistically significant association with disability [P < 0.001, [Table 3]].
Table 3: Correlation of YMRS score with disability

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  Discussion Top

Disability is increasingly recognized as crucial factor in assessing the impact of mental health illnesses on functional outcome and quality of life.[2],[14] In the present study, the pattern of disability associated with BPAD was assessed using IDEAS and correlated with sociodemographic and clinical variables. There was a statistically significant correlation between disability and age group (P = 0.001) indicating that disability increased with increasing age, which is in concurrence with the Indian study done by Thomas et al.[1] However, Mixed-Effects Modeling research done on USA and European populations by Bennett et al.[9] did not find any correlation between age and gender with the psychosocial outcome in a longitudinal study to assess the psychosocial outcome using GAF score. This variation could be due to the use of a different methodological design of the study.

This study results agree with the previous research studies.[1],[25] Possible reasons for excess of disability in women can be the later onset of manic episodes, rapid cycling, and prolonged and more depressive episodes.[25] Also, comorbidity of medical and psychiatric disorders is more common in women than men and adversely affects recovery from bipolar disorder more often in women. Comorbidity, particularly thyroid disease, migraine, obesity, and anxiety disorders occur more frequently in women than men.[26] However, considerably less attention has been paid to gender differences in terms of disability (either type or severity) and it is not clear whether women are more disabled by their illness than men. Marriage is considered to have stabilizing effect on a person's life and spouse could be the pillar of social support system in many instances. The disability status of the married and single (unmarried/separated/divorced) groups were comparable and in the mild range. An explanation for this result could be that in Indian culture, living in extended/joint families is common and this provides necessary social support to the patient despite being single. These findings are not in complete agreement with the previous foreign studies[10],[11],[27] confirming the cultural differences.

In our study, 82% patients had duration of illness more than 10 years. Even though duration of illness parameter has been given importance in Indian disability evaluation and assessment scale (IDEAS), no statistical significance was found between duration of illness and disability contrary to the earlier studies.[12],[16] Our study found a statistically significant association between number of episodes and disability, which is in concurrence to the earlier studies.[7],[12],[13] This highlights that the recurrent course of BPAD is associated with more disability. We could not find a significant association between repeated previous hospitalizations (more than 3) and overall psychosocial impairment, which is not in line with the previous studies done by Gutierrez et al.[8] and Jiménez et al.[13] This disagreement could be due to the inclusion of Axis I and II comorbidities by these researchers, which itself (comorbidities) can contribute to the disability.

There were no patients with severe disability. The likely reason can be that our study sample was in inter episodic phase and most patients were gainfully employed indicating better functioning. On individual domain “Interpersonal activities” was the domain maximally affected and Self-care was the domain least affected. The Indian study by Chaudhury et al.[18] using IDEAS also found that all the core areas of functioning, i.e., self-care, interpersonal relations, communication, and work are affected in BPAD patients and interpersonal relations is the area maximally affected. Sanchez-Moreno et al.[5] in their systematic review concluded that the subsyndromal symptoms (manic or depressive) play a major role in the low functioning and disability involving all the domains of functionality. Most of the patients in our study had YMRS score of 5 or less (88%) indicating remission phase and only 12% had score more than or equal >=6, which indicates subsyndromal manic (SSM) symptoms. We found a statistically significant association between SSM features and disability in concordance with the study results of secondary analysis on subthreshold cases.[27]

In the natural course of the BPAD, patients spend greater time in depressive phase compared to manic phase leading to more psychosocial disability, which is directly related to severity of depressive symptoms.[7],[8],[13] In our study, even though no cutoff score of HAM-D was used, inclusion of treatment compliant patients, which in itself is a good prognostic factor, and absence of depressive symptoms may be the reasons for lower range of disability. Several systematic review studies[5],[6],[14],[15] have highlighted the role of neurocognitive impairment being the major contributor for the functional impairment in BPAD, it would be helpful to incorporate assessment of cognitive functioning for disability assessment as IDEAS has limitations for the same. Thus, the purposive sampling, cross-sectional design, and stringent inclusion criteria could be the major reasons for the less disability (mild to moderate) in our study sample, which are limitations.

Our study focused on disability associated with BPAD in the Indian context where limited research has been done till date. This study identifies that BPAD is associated with mild-to-moderate disability as per IDEAS, which is a standard evaluation tool in India for assessing disability due to psychiatric illness.

  Conclusion Top

In the present study, we have evaluated sociodemographic and clinical variables of BPAD and its correlation with disability using the Indian Disability Evaluation and Assessment Scale (IDEAS). We found that BPAD is associated with mild-to-moderate disability. There was a statistically significant association of age, gender, subsyndromal manic features, and number of previous episodes with disability. There is a need for further studies on the utility of IDEAS scale and its individual domains in the assessment of disability due to BPAD for replication of the results.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Thomas SP, Nisha A, Varghese PJ. Disability and quality of life of subjects with bipolar affective disorder in remission. Indian J Psychol Med 2016;38:336-40.  Back to cited text no. 1
[PUBMED]  [Full text]  
Michalak EE, Yatham LN, Maxwell V, Hale S, Lam RW. The impact of bipolar disorder upon work functioning: A qualitative analysis. Bipolar Disord 2007;9:126–43.  Back to cited text no. 2
World Health Organization. International classification of functioning, disability and health (ICF). Geneva: World Health Organization; 2001.  Back to cited text no. 3
India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India: The Global Burden of Disease Study 1990-2017. Lancet Psychiatry 2020;7:148-61.  Back to cited text no. 4
Sanchez-Moreno J, Martinez-Aran A, Tabares-Seisdedos R, Torrent C, Vieta E, Ayuso-Mateos JL. Functioning and disability in bipolar disorder: An extensive review. Psychother Psychosom 2009;78:285-97.  Back to cited text no. 5
Martinez-AA, Vieta E, Torrent C, Sanchez-Moreno J, Goikolea JM, Salamero M, et al. Functional outcome in bipolar disorder: The role of clinical and cognitive factors. Bipolar Disord 2007;9:103–13.  Back to cited text no. 6
Rosa AR, Reinares M, Michalak EE, Bonnin CM, Sole B, Franco C, et al. (2010). Functional impairment and disability across mood states in bipolar disorder. Value Health 2010;13:984–8.  Back to cited text no. 7
Gutierrez RL, Jurado D, Gurpeguie M. Factors associated with work, social life and family life disability in bipolar disorder patients. Psychiatry Res 2011;186:254-60.  Back to cited text no. 8
Bennett F, Hodgetts S, Close A, Frye M, Grunze H, Keck P, et al. Predictors of psychosocial outcome of bipolar disorder: Data from the Stanley Foundation Bipolar Network. Int J Bipolar Disord 2019;7:28.  Back to cited text no. 9
Blairy S, Linotte S, Souery D, Papadimitriou GN, Dikeos D, Lerer B, et al. Social adjustment and self-esteem of bipolar patients: A multicentric study. J Affect Disord 2004;79:97–103.  Back to cited text no. 10
Romans SE, McPherson HM. The social networks of bipolar affective disorder patients. J Affect Disord 1992;25:221-8.  Back to cited text no. 11
Chacko D, Narayan KT, Prabhavathy KS. Disability in patients with bipolar and recurrent depressive disorder in remission: A comparative study. Indian J Psychol Med 2011;33:49-53.  Back to cited text no. 12
[PUBMED]  [Full text]  
Jiménez E, Arias B, Castellví P, Goikolea JM, Rosa AR, Fañanás L, et al. Impulsivity and functional impairment in bipolar disorder. J Affect Disord 2012;136:491–7.  Back to cited text no. 13
Chen M, Fitzgerald HM, Madera JJ, Tohen M. Functional outcome assessment in bipolar disorder: A systematic literature review. Bipolar Disord 2019;21:194-214.  Back to cited text no. 14
Tabarés-Seisdedos R, Balanzá-Martínez V, Sánchez-Moreno J, Martinez-Aran A, Salazar-Fraile J, Selva-Vera G, et al. Neurocognitive and clinical predictors of functional outcome in patients with schizophrenia and bipolar I disorder at one-year follow-up. J Affect Disord 2008;109:286-99.  Back to cited text no. 15
Tohen M. Functionaloutcome assessment in bipolar disorder: A systematic literature review. Bipolar Disord 2019;21:194–214.  Back to cited text no. 16
Math SB, Gowda GS, Basavaraju V, Manjunath N, Kumar CN, Philip S, et al. The rights of persons with disability act, 2016: Challenges and opportunities. Indian J Psychaitry 2019;61(Suppl S4):809-15.  Back to cited text no. 17
Chaudhury PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95–101.  Back to cited text no. 18
[PUBMED]  [Full text]  
Zarate CA, Tohen M, Land M, Cavanagh S. Functional impairment and cognition in bipolar disorder. Psychiatr Q 2000;71:309-29.  Back to cited text no. 19
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 21
Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: Reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35.  Back to cited text no. 22
Gururaj, Maheshvaran. Kuppuswamy's socio economic status scale- A revision of income parameters for 2014. Int J Recent Trends Sci Technol 2014;11:1-2.  Back to cited text no. 23
Guidelines for evaluation and assessment of mental illness and procedure for certification. Ministry of Social Justice and empowerment, Government of India. 27th February 2002. Available from: http://socialjustice.nic.in/disabled/mentguide.htm#manual  Back to cited text no. 24
Robb JC, Young LT, Cooke RG, Joffe RT. Gender differences in patients with bipolar disorder influence outcome in the medical outcomes survey (SF-20) subscale scores. J Affect Disord 1998;49:189–93.  Back to cited text no. 25
Arnold LM. Gender differences in bipolar disorder. Psychiatr Clin North Am 2003;26:595-620. [doi: 10.1016/s0193-953x(03)00036-4. PMID: 14563100].  Back to cited text no. 26
Judd LL, Akiskal HS. The prevalence and disability of bipolar spectrum disorders in the US population: Re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord 2003;73:123–31.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3]


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