The Unrecognized Side of Bipolar Disorder

Over a century ago, Emil Kraepelin divided “endogenous psychoses” into two separate disease categories—dementia praecox (schizophrenia) and manic-depressive illness (bipolar disorder and recurring unipolar disorder) (1). He described a clear difference in the course of these disorders: dementia praecox was chronic and deteriorating, whereas manic-depressive illness was episodic with a return to normal functioning between episodes.

Although many of Kraepelin’s ideas have stood the test of time, his assertion that manic-depressive illness is episodic with interepisode normal functioning has not. In the National Institute of Mental Health Treatment of Depression Collaborative Research Program, for example, one in 10 bipolar patients and one in five depressed patients remain chronically ill (2, 3). These findings refer to symptomatic status, that is, whether the patient is in a clinical episode, is in partial remission, or is in remission based on assessment of symptoms (such as mood, energy level, suicidal ideation, and rate of speech). But what happens with psychosocial status? Whether psychosocial functioning and cognitive functioning in particular return to premorbid levels over time in patients with mood disorders has received far less attention in the research literature. How well the patient can function in his or her day-to-day life is of great importance.

The issue of life function was addressed poignantly in a recent article by Linda Logan in the New York Times Magazine (4) in which the author provides a firsthand account of her several decades’ battle with bipolar disorder. She describes her loss of “self” as a result of bipolar disorder. She describes vividly how the illness and the treatments affected her basic abilities to adapt and to behave. “Word retrieval was difficult and slow. It was as if the door to whatever part of the brain that housed creativity had locked. Clarity of thought, memory, and concentration had all left me. I was slowly fading away.”

Vieta and his colleagues in Spain have been studying psychosocial functioning in patients with bipolar disorder for over a decade. They have noted that two-thirds of bipolar patients do not achieve full social and occupational recovery and do not return to their premorbid functional levels. Contributing to this functional impairment are neurocognitive deficits. In their earlier work, Vieta et al. reported that bipolar patients, whether in a manic state or a depressed state, had significantly impaired neuropsychological functioning compared with healthy subjects (5). They found significant cognitive dysfunction in verbal memory and in formal executive functioning (e.g., planning, problem solving, verbal reasoning, and monitoring of actions). When they followed these patients into remission, they found that the cognitive deficits persisted at 1 year and at 2 years (6, 7). They reported that executive functioning and processing speed remained impaired over time in patients who were well treated and euthymic.

These findings of persistent cognitive impairment should come as no surprise to those of us who treat bipolar patients. Unfortunately, the research literature has provided very little that we can offer to our patients to help prevent, manage, or improve these impairments. We have focused almost exclusively on efficacy, and not enough on the fundamental psychosocial concerns about which Logan writes so movingly.

Vieta and his colleagues have developed a treatment program to address those impairments in bipolar patients—“functional remediation” (see Martínez-Arán et al. [8]). The functional remediation program consists of 21 weekly sessions, 90 minutes apiece. The sessions address attention, memory, and executive function, as well as general psychosocial functioning.

In this issue of the Journal, Torrent et al. (9) describe the first test of functional remediation in bipolar patients. The study involved three treatment arms: functional remediation, a psychoeducational program (which they also developed), and treatment as usual. The psychoeducational program was designed to prevent recurrences of bipolar disorder by focusing on illness awareness, treatment adherence, early detection of prodromal symptoms, and lifestyle regularity. The sample included 239 patients with bipolar I or II disorder who had been in remission for at least 3 months and exhibited a moderate to severe functional impairment at baseline. Patients were randomly assigned to one of the three treatment conditions.

At the end of the study, psychosocial function had improved significantly more in patients who had been in the functional remediation program than those receiving treatment as usual. The improvements were most striking in the domains of interpersonal functioning and occupational functioning. Furthermore, more than 5% of patients in the functional remediation group were able to get a job during the treatment phase, compared with none in the treatment-as-usual group. The largest improvements in psychosocial functioning between the functional remediation and psychoeducation groups were in the cognitive, autonomy, occupational, and leisure domains.

This landmark study and its findings represent an important first step in the development of evidence-based strategies to address and improve cognitive deficits associated with bipolar disorder. The details of functional remediation are described in an English translation of the manual, due to appear in January (10). I urge all clinicians to read it and to incorporate its techniques into our practices.