Residual symptoms in bipolar disorder: The effect of the last episode after remission

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Abstract

In this study it is aimed to assess interepisode residual symptoms in remitted bipolar disorder patients with a hypothesis that the last episode recovered has implications on residual symptomatology. The study was carried out with 23 bipolar patients diagnosed as mania (BP-M) and 20 bipolar patients diagnosed as depression (BP-D) in their last episode, and with 22 healthy controls in a university hospital clinic. All patients were in remission for at least 6 months. In the assessment Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), Stroop Test, Auditory Verbal Learning Test (AVLT), increased latency positive-evoked potentials (P300), Global Assessment of Functioning Scale (GAF), and Social Functioning Scale (SFS) were used cross-sectionally. In affective symptomatology, the BP-M group had higher YMRS scores, and the BP-D group had higher HAM-D scores compared to the controls. P300 test results revealed low amplitude in the BP-D group. In the AVLT, verbal learning and delayed recall were significantly lower in the two bipolar groups. The Stroop tasks were not different in the groups. Concerning the SFS, social withdrawal was impaired in the two bipolar groups, whereas dependency–competency was impaired in the BP-M and employment/occupation was impaired in the BP-D group. As a conclusion, bipolar patients recovering from depressive episode may experience more impairment in daily functioning due to residual depressive symptoms and impairment of attention and memory.

Introduction

Even though bipolar disorder is suggested to have a benign course with episodes and remissions, Angst et al. (1980) showed that 24% of bipolar patients have residual symptoms during the intervals between episodes in a longitudinal follow-up study. In bipolar patients with symptoms of residual mania or depression, cognitive symptoms are reported to be the most common, and mood symptoms are the second most common in the residual phase. Social, behavioral and neurovegetative symptoms are less important (Keitner et al., 1996).

These cognitive symptoms have been studied with a variety of neuropsychological testing batteries. Martinez-Aran et al. (2004a) reported cognitive dysfunction in verbal memory and frontal executive tasks in euthymic bipolar patients. Poorer performance was also detected on measures of verbal learning, executive functioning and motor coordination in BD patients compared to control volunteers (Zubieta et al., 2001). Clark et al. (2002) reported that bipolar I patients were impaired on tasks of attentional set shifting, verbal memory and sustained attention where they indicated that only sustained attention deficit survived controlling for mild affective symptoms. Likewise, when controlled for age, premorbid IQ and depressive symptoms, patients with euthymic bipolar disorder performed worse than control subjects on executive functions (Ferrier et al., 1999). Martinez-Aran et al. (2002) reported verbal fluency deficits and impairment in executive functioning in euthymic bipolar patients related to a poor social outcome. In their review, Quraishi and Frangou (2002) pointed out that impairment in verbal memory is reliably documented, and both residual manic and depressive symptoms result in deficits in the number of perseverative errors, verbal fluency and planning ability. It is also estimated that 30–50% of largely remitted patients fail to attain premorbid levels of psychosocial functioning due to their cognitive impairment (Quraishi and Frangou, 2002, Goodwin and Jamison, 1990).

Furthermore, even though symptomatic improvement is achieved in bipolar disorder, approximately 20–30% of the patients have impairment in social functioning (Ceylan and Oral, 2001). Social maladjustment such as impaired work adjustment, impaired social and leisure activities adjustment and impaired marital adjustment was demonstrated in recovered bipolar patients (Bauwens et al., 1998). Moreover, cognitive impairment may affect occupational and social functioning as well as quality of life (Vieta et al., 2002).

Interepisode symptoms warrant concern as they may engender considerable disability and impairment. Even though residual symptoms are well-known and well-studied, the nature of these symptoms is a topic of interest. It is not well-documented whether residual affective symptoms cause impairment in cognitive functions or cognitive impairment per se is the source of psychosocial dysfunction during remission. In this present study, it is aimed to assess remitted bipolar patients in terms of affective, cognitive and social functioning. In order to better understand the effect of the residual symptomatology of bipolar disorder, the patient group is divided into two subgroups according to their last episode—whether the last episode is manic or depressive. To our knowledge, this is the first study to assess the interepisode symptoms taking the last episodes into consideration.

Section snippets

Setting

The study was carried out in the Department of Psychiatry, Celal Bayar University Hospital, Manisa, Turkey between March and December 2005. Patients were recruited from the Unit for Mood Disorders in this department. All patients were being followed-up by the second author (OA).

Subjects

Bipolar patients were chosen according to their last affective episode. The inclusion criteria were being at the age of between 18 and 65, being in remission for at least 6 months, having a diagnosis of bipolar disorder

Demographical features

The demographical and clinical features of the bipolar and control groups are demonstrated in Table 1. There was no statistical difference between the groups in terms of demographical and clinical features. The only difference among the bipolar groups is that the BP-M group had a younger age of onset when compared to the BP-D group (t =  1.119, p = .012).

Table 2 shows the medications that were used at the time of the study assessment. There was no statistical difference between the BP-D and BP-M

Discussion

The majority of the studies indicate that QoL is markedly impaired in patients with BD, even when they are considered to be clinically euthymic (Michalak et al., 2005). There is a growing interest in residual symptoms in bipolar disorders since they are related to the impairment of quality of life. Furthermore, residual symptoms are also related to the recurrences in bipolar disorder (Perlis et al., 2006). In this present study, the nature of the residual symptoms in bipolar disorder is

Acknowledgement

This study was granted by the Scientific and Research Project Committee of Celal Bayar University (2005-006).

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