ABSTRACT
Objective: To determine the main predictors of functioning in patients with BD.
Methods: Thirty-five patients with BD type I in remission participated in this study. To better characterize the degree of impairment, 20 matched controls were also studied. Functioning was assessed through the Functioning Assessment Short Test (FAST) and the UCSD Performance-based Skills Assessment (UPSA), while cognition was assessed through the BAC-A. Current physical conditions were assessed and categorized according to the Cumulative Illness Rating Scale (CIRS). Regression analyses were performed to examine the relationship between functioning and clinical variables, global cognitive performance, and physical comorbidities in BD.
Results: UPSA correlated positively with the BAC-A total score (r=0.488; p=0.025), years of education (rho=0.41; p<0.01), and CIRS total score (rho=0.394; p<0.001). CIRS was the only predictor that remained negatively and significantly correlated with the UPSA total score (R
2=0.446, F (1, 33)=8.198, p=0.007).
Conclusion: Patients with BD had poor functioning, with the primary determinant of poor functioning being the burden of physical illnesses. In addition, the low agreement between the FAST and UPSA scales suggests these tolls assess distinct constructs.
Keywords: Bipolar Disorder, Mania, Psychosocial Functioning, Functional Status, Social Interaction, Cognitive Dysfunction.
RESUMO
Objetivo: O presente estudo tem como objetivo determinar os principais preditores de funcionamento em pacientes com TB.
Métodos: Trinta e cinco pacientes com TB I em remissão participaram deste estudo. Para melhor caracterizar o grau de comprometimento, 20 controles também foram estudados. O funcionamento foi avaliado por meio do
Functioning Assessment Short Test (FAST) e do UCSD
Performance-based Skills Assessment (UPSA), enquanto a cognição foi avaliada por meio do Brief Assessment of Cognition in Affective Disorders (BAC-A). As condições físicas atuais foram avaliadas e categorizadas de acordo com a
Cumulative Illness Rating Scale (CIRS). Análises de regressão foram realizadas para examinar a relação entre funcionamento e desempenho cognitivo global e comorbidades físicas no TB.
Resultados: O UPSA correlacionou-se positivamente com a pontuação total do BAC-A (r=0,488; p=0,025), anos de educação (rho=0,41; p<0,01) e pontuação total do CIRS (rho=0,394; p<0,001). O CIRS foi o único preditor que permaneceu negativa e significativamente correlacionado com a pontuação total do UPSA (R
2=0,446, F (1, 33)=8,198, p=0,007).
Conclusão: Pacientes com TB apresentaram mau funcionamento, sendo o principal determinante de mau funcionamento a carga de doença física. Além disso, a baixa concordância entre as escalas FAST e UPSA sugere que essas ferramentas avaliam construtos distintos.
Palavras-chave: Transtorno Bipolar, Mania, Funcionamento Psicossocial, Estado Funcional, Interação Social, Disfunção Cognitiva.
Carátula del artículo
Social functioning in bipolar disorder: investigating the role played by comorbid physical illnesses and cognition
Funcionamento social no transtorno bipolar: investigando o papel das comorbidades físicas e da cognição
Isabela Martins Becattini Pereira
Universidade Federal de Minas Gerais, Brazil
Universidade Federal de Minas Gerais, Brazil
Lucas Machado Mantovani
Fundação Hospitalar do Estado de Minas Gerais, Brazil
Faculdade de Ciências Médicas de Minas Gerais, Brazil
Gabriel Anselmo Frota
Universidade Federal de Minas Gerais, Brazil
Raphael Rocha Wenceslau
Universidade Federal de Minas Gerais, Brazil
Juliana Cunha Matos
Faculdade de Ciências Médicas de Minas Gerais, Brazil
Breno Fiuza Cruz
Universidade Federal de Minas Gerais, Brazil
Universidade Federal de Minas Gerais, Brazil
Antônio Lúcio Teixeira
The University of Texas Health Science Center at Houston, United States
Faculdade Santa Casa Belo Horizonte, Brazil
Izabela Guimarães Barbosa izabelagb@gmail.com
Universidade Federal de Minas Gerais, Brazil
Universidade Federal de Minas Gerais, Brazil
Universidade Federal de Minas Gerais, Brazil
Dementia & Neuropsychologia, vol. 19, e20240188, 2025
Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento
Received: 15 July 2024
Revised document received: 13 November 2024
Accepted: 28 November 2024
Funding
Funding source: FAPEMIG
Funding source: Brazilian National Council for Scientific and Technological Development
Contract number: APQ-02313-18
Funding statement: This study was partially funded by FAPEMIG (Fundação de Amparo a Pesquisa de Minas Gerais) - Grant APQ-02313-18. ALT is supported by the Brazilian National Council for Scientific and Technological Development (CNPq – Bolsa de Produtividade em Pesquisa).
INTRODUCTION
Functioning is a complex concept related to being able to perform social roles, such as working, studying, managing household chores, and maintaining personal relationships with others
1. Functioning can also refer to the ability to perform activities of daily life in an autonomous and independent manner
2. Aging and chronic physical illnesses are major drivers of functional impairment
3. The presence of any physical comorbidity is an important factor related to disability, and specific combinations of chronic conditions are particularly relevant to increase functional impairment, such as diabetes and cardiovascular diseases
4,
5.
Bipolar disorder (BD) is a complex and chronic psychiatric disorder marked by a pattern of chronic and/or recurrent mood swings. Even with adequate mood stabilization and remission of mood symptoms, BD is associated with significant functioning impairment. Factors such as older age, low income, subsyndromal depressive symptoms, and poor executive functions, verbal memory, working memory, and verbal fluency, have been associated with functional impairment in BD
6,
7,
8. The role of cognitive performance in functioning cannot be overlooked. Poorer global functioning in BD has consistently been associated with cognitive performance
9. Furthermore, the occurrence of mood episodes can add significant functional burden to patients. While depressive symptoms can impact mainly work, autonomy, and interpersonal relationships, manic/hypomanic symptoms influence autonomy and financial skills
10,
11.
No previous study has simultaneously evaluated functioning in patients with BD considering both physical comorbidities and cognitive parameters. To control for the effect of mood episodes, we assessed patients with BD in euthymia. We also assessed the potential overlap of two functioning tools: one based on patients’ beliefs/opinion (Functioning Assessment Short Test – FAST) and the other based on structured clinical assessment (Performance-based Skills Assessment – UPSA). We hypothesized that poor cognition and the severity of chronic physical conditions are the main determinants of poor functioning in patients with BD.
METHODS
Subjects
This is a convenience sample study that recruited 35 patients with BD type I in remission and 20 matched controls. Participants were aged between 18 and 65 years old. Clinical assessment of research participants included demographic and clinical information, such as sex, age, length of illness. Current chronic physical conditions were assessed and categorized according to the Cumulative Illness Rating Scale (CIRS)
12.
Patients were consecutively recruited from an outpatient psychiatric clinic specialized in BD at Hospital das Clínicas de Minas Gerais (EBSERH-HC/UFMG), Belo Horizonte. Patients were assessed with the Hamilton Depression Rating Scale (HDRS) (17-item version)
13, and the Young Mania Rating Scale (YMRS)
14 to determine the severity of depressive and manic symptoms, respectively. Inclusion criterion for BD was remission, defined by YMRS and HDRS scores lower than 7 points for 8 consecutive weeks. The only exclusion criterion for participants was illiteracy and participants whose Mini-Mental State Examination (MMSE) scores were below cut-off points indicative of cognitive impairment (see below). Controls were recruited from the community and had no history of psychiatric disorders or family history of such conditions.
All volunteers provided their written consent after a complete explanation of the procedures involved in the research protocol. Data were collected in 2021. The local institutional review board approved the study, which is in accordance with the 1975 Helsinki Declaration. All tests were administered by the same researcher (psychiatrist).
Functioning assessment
Functioning assessment included the FAST
15,
16 and the UPSA
17. The FAST is a brief questionnaire designed to assess the main functional difficulties in patients with BD. It has been translated and validated for use in Brazil
15. It consists of 24 items covering six distinct functional areas:
The scale ranges from 0 to 72 points, with higher scores indicating worse functioning
16. FAST scores between 0-11 indicate no functional impairment, between 12-20 indicate mild functional impairment, between 21 to 40 indicate moderate functional impairment, and above 40 indicates severe functional impairment
17.
The UPSA
18 is a test developed for the assessment of functioning using controlled scenarios that replicate daily life situations. It assesses basic skills across five areas:
It has been translated and validated for use in Brazil
19. The score for each domain varies between 0 and 20, resulting in a final score between 0 and 100. The closer to 100, the lesser functioning impairment.
Cognitive assessment
The cognitive examination included the MMSE
20 and the Brief Assessment of Cognition in Affective Disorders (BAC-A)
21,
22,
23. The BAC-A comprises eight tasks (affective interference, verbal memory, working memory, motor speed, semantic and letter fluency, executive functioning, attention and motor speed) informing about the supposedly most affected cognitive domains in BD. It provides a global cognitive performance score.
We used the MMSE cut-off scores for cognitive impairment according to schooling years: 21 for illiterates, 22 for those with up to 5 years of education, 23 for those with 6 to 11 years of education, and 24 for those with 12 or more years of education
20. Both psychiatric and cognitive assessments were performed on the same day, with each subject requiring approximately 90 minutes to be completed.
Statistical analysis
Differences in dichotomous variables (sex and presence of clinical comorbidities) were tested using the Chi-square test. For continuous variables, means, medians, standard deviations, and total range are presented. All variables were tested for normality of distribution by the Kolmogorov-Smirnov test. Non-parametric Mann-Whitney tests were used for group comparisons. Statistical analyses were conducted using SPSS 22.0 (SPSS Inc., Chicago, Illinois). All statistical tests were two-tailed, with a significance level of α=0.05.
The scores from BAC-A were standardized into z-scores (M±SD: 0±1)
21,
22. The total score of BAC-A was calculated by summing the standardized z-score across the eight cognitive domains (Global performance score).
The correlational analysis between the variables among patients with BD was performed using Spearman’s test. A multiple regression analysis was performed whereby the dependent variable was UPSA and the predictors were years of education, BAC-A, and CIRS (variables p<0.05 on univariate analyses) in patients with BD. A backward elimination procedure was applied and variables with the highest p value were progressively deleted from the model. The final model retained variables with a significance level ≤0.05.
To analyze the UPSA-1-BR ability to determine functioning of patients with BD, its scores were compared to the FAST cut-off point using the Receiver Operating Characteristic (ROC) curve. McNemar’s test was conducted to verify the degree of agreement between the scales. In addition, Kappa’s test was performed to verify whether the UPSA-1-BR alterations were consistent with those identified by FAST in patients with BD.
RESULTS
Demographic, clinical features, cognitive, and functioning assessment
As shown in
Table 1, patients with BD and controls presented similar distribution for age, sex, years of education, and physical comorbidities. All participants were cisgender. All patients were medicated, 71.4% (25/35) were in use of lithium, 40.0% (14/35) were in use of anticonvulsants, 28.6% (10/35) were in use of atypical antipsychotics, and 11.4% (4/35) were in use of antidepressants. On the BAC-A, the standard deviation of the z-scores for the global performance score was 1.09. Patients with BD presented a higher CIRS total score compared to controls (p<0.001); 57.1% (20/35) patients with BD scored 2/4 at Endocrine-Metabolic CIRS subscale; 8.6 (3/35) patients with BD scored 3/4 at Endocrine-Metabolic CIRS subscale; 71.7% (25/35) patients with BD scored 3/4 at Psychiatric CIRS subscale, and 28.6% (10/35) patients with BD scored 4/4 at Psychiatric CIRS subscale.
Table 1
Sociodemographic and clinical features of patients with bipolar disorder in comparison with controls.
Abbreviations: BD, bipolar disorder; N, subjects; P, percentile; HAM-D, Hamilton Depression Scale; Young, Young Mania Scale; CIRS, Cumulative Illness Rating Scale; FAST, Functioning Assessment Short Test; UPSA, UCSD Performance-based Skills Assessment. Notes: *Mann-Whitney’s test †Chi-square test
‡Fisher’s exact test.
Functioning assessment
According to the FAST scale, 74.3% of patients scored above 11 points (p<0.001), indicating functioning impairment. According to the UPSA scale, 43.0% of patients scored above 75 points. When compared to controls, patients with BD had poorer UPSA total scores (p<0.001), particularly in the domains of understanding and planning (p=0.02), financial skills (p<0.001), communication (p<0.001), and transport (p<0.001).
Functioning determinants in patients with bipolar disorder
As demonstrated in the
Table 2, UPSA correlated positively with the BAC-A total score (r=0.488; p=0.025), years of education (rho=0.41; p<0.01), and CIRS total score (r=0.394*; p<0.001). CIRS was the only predictor that remained negatively and significantly correlated with the UPSA total score (R2=0.446, F (1, 33) = 8.198, p=0.007). There was no correlation between age and UPSA or FAST scores.
Table 2
Function determinants in patients with bipolar disorder.
Abbreviations: CIRS, Cumulative Illness Rating Scale; UPSA, UCSD Performance-based Skills Assessment; FAST, Functioning Assessment Short Test. Notes: *p<0.01 †p<0.05.
Contrasting different functioning scales in patients with bipolar disorder
Of the 23 patients that presented functioning impairment as measured by the FAST, seven (30.4%) did not show impairment according to the UPSA scores. Conversely, three of the 15 patients (20.0%) with impaired functioning measured by UPSA did not present impairment on the FAST. The Kappa value was 0.2, indicating low agreement between the FAST and UPSA scales.
DISCUSSION
In this clinic-based study involving euthymic patients with BD, the primary determinant of poor functioning was the burden of chronic physical illness. The findings also demonstrated a low agreement between the FAST and UPSA scales, suggesting that these two scales assess distinct constructs and may be best applied together to provide a more comprehensive evaluation of functioning in BD.
Previous studies reported poor functioning in BD, primarily during mania episodes
24,
25 or depressive states
24,
25,
26. To control for the effects of mood episodes, only research participants in euthymia were recruited for this study. Previous studies have shown that just one third of patients with BD in remission recover their previous level of functioning
7. Accordingly, compared to healthy controls, our sample exhibited mild to moderate functional impairment, particularly at being independent, working, and performing cognitive tasks. A recent meta-analysis demonstrated that individuals at risk for BD also demonstrated poorer functioning than controls
27. Altogether, these findings suggest that poor functioning might be a trait marker of BD.
This is the first study to assess the agreement between measures of functioning based on patients’ beliefs (
i.e., FAST scale) and functioning evaluated by an experienced clinician through controlled environment tests (
i.e., UPSA). A higher proportion of patients with BD appear to present poor functioning according to FAST compared to the UPSA. One hypothesis is that self-assessment has a negative impact on functioning evaluation, as patients with BD might lack full awareness of their own capabilities, leading to inaccurate self-estimations of performance. Conversely, UPSA provides measurements related to the ability to perform activities of daily life in an autonomous and independent manner
28. It is measured through role-playing tasks in a controlled environment, being less susceptible to influences such as insight, personal values, or contextual variations
29. These methodological differences likely account for the discrepancies observed in functioning assessments between UPSA and FAST in BD. Therefore, both scales should be applied to provide a more comprehensive assessment of functioning in patients with BD, a point that must be addressed in future studies.
In the current study, the primary determinant of poor functioning was the burden of physical illnesses. A recent cohort study including patients from seven countries found that lower community functioning in BD was associated with depressive symptoms, lower levels of education, a greater number of prior mood episodes, and the presence of a comorbid substance use disorder
30. Besides these predictors, the assessment of chronic physical diseases must be considered, also informing about mortality, hospital readmission, and prolonged hospital stays
31. Indeed, physical comorbidities influence the functioning and the quality of life, particularly in severe mental illness
32. CIRS evaluates the cumulative burden impact of physical comorbidities on heath. Patients with BD tend to have more comorbidities than controls, regardless of the age group considered
33,
34. However, it remains to be determined whether improved treatment or management of physical comorbidities can affect functioning of individuals with BD.
Of note, endocrine and metabolic conditions had a significant impact on the CIRS total score, considering that 65.71% of patients with BD had moderate or severe issues in the Endocrine-Metabolic CIRS subscale. This is related to the high incidence of overweight and obesity within this demographic
35,
36. Our study also demonstrated that patients with BD presented poor functioning independently of cognitive impairment. In fact, functioning is a construct influenced by sociodemographic factors, years of study, and biological processes such as a mild chronic inflammatory profile
2. While cognitive impairments in patients with BD appear to strongly influence social and occupational domains of functioning, their relationship to global functioning is less pronounced
37.
Our study has several limitations. First, the cross-sectional design precludes any causality assumption. Second, the small sample size limits the generalization of the findings to the broader population of patients with BD. The patients studied had a long disease duration and were followed at a specialized service. Third, while patients did not fulfil criteria for major neurocognitive disorder, it is possible that subclinical and/or mild cognitive symptoms, not captured by the limited cognitive assessment performed, were present. Conversely, the inclusion of only euthymic patients strengthens the study, as functioning is known to be impaired during mood episodes
38. All patients were medicated with mood stabilizers and/or antipsychotics, which can influence metabolic parameters. Interestingly, while medications are often associated with weight gain, historical observations by authors such as Kretschmer, even before the advent of psychopharmacology, associated a somatic typology (
i.e. habitus picnicus, characterized by abdominal fat pattern) to an increased risk of developing manic-depressive psychosis
39. More recent evidence confirms that BD is associated with increased weight, regardless of treatment with antipsychotics and mood stabilizers
40. The researcher was not blinded to participant status, as patients were recruited from a mood disorder clinic and controls from the community. Future research must address these limitations by including larger samples, deeper cognitive phenotyping (
i.e., assessing additional domains with multiple tools), and longitudinal design to explore changes over time.
In conclusion, our findings indicate that patients with BD present impaired functioning, especially those with chronic physical comorbidities. A comprehensive treatment plan addressing both psychiatric and clinical/physical comorbidities might help prevent or mitigate trajectories of cognitive and functional impairment in BD.
ACKNOWLEDGMENTS
We are grateful to the patients and their families for their contribution to this study.
REFERENCES
Ryu S, Lee H, Lee DK, Nam HJ, Chung YC, Kim SW. Network structures of social functioning domains in schizophrenia and bipolar disorder: a preliminary study. Clin Psychopharmacol Neurosci. 2020;18(4):571-9. https://doi.org/10.9758/cpn.2020.18.4.571
Mantovani LM, Teixeira AL, Salgado JV. Functional capacity: a new framework for the assessment of everyday functioning in schizophrenia. Braz J Psychiatry. 2015;37(3):249-55. https://doi.org/10.1590/1516-4446-2014-1551
Fried LP, Guralnik JM. Disability in older adults: evidence regarding significance, etiology, and risk. J Am Geriatr Soc. 1997;45(1):92-100. https://doi.org/10.1111/j.1532-5415.1997.tb00986.x
Fong JH. Disability incidence and functional decline among older adults with major chronic diseases. BMC Geriatr. 2019;19(1):323. https://doi.org/10.1186/s12877-019-1348-z
Zhao Y, Zhang Y, Teopiz KM, Lui LMW, McIntyre RS, Cao B. Presence of depression is associated with functional impairment in middle-aged and elderly chinese adults with vascular disease/diabetes mellitus-a cross-sectional study. Int J Environ Res Public Health. 2023;20(2):1602. https://doi.org/10.3390/ijerph20021602
Solé B, Bonnim CM, Torrent C, Balanzá-Martínez V, Tabarés-Seisdedos R, Popovic D, et al. Neurocognitive imparirment and psychosocial functioning in bipolar II disorder. Acta Psychiatr Scand. 2011;125(4):309-17. https://doi.org/10.1111/j.1600-0447.2011.01759.x
Gitlin MJ, Miklowitz DJ. The difficult lives of individuals with bipolar disorder: a review of functional outcomes and their implications for treatment. J Affect Disord. 2017;209:147-54. https://doi.org/10.1016/j.jad.2016.11.021
Roux P, Raust A, Cannavo AS, Aubin V, Aouizerate B, Azorin JM, et al. Associations between residual depressive symptoms, cognition, and functioning in patients with euthymic bipolar disorder: results from the FACE-BD cohort. Br J Psychiatry. 2017;211(6):381-7. https://doi.org/10.1192/bjp.bp.117.201335
Comes M, Rosa A, Reinares M, Torrent C, Vieta E. Functional impairment in older adults with bipolar disorder. J Nerv Ment Dis. 2017;205(6):443-7. https://doi.org/10.1097/NMD.0000000000000683
Grunze H, Born C. The impact of subsyndromal bipolar symptoms on patient’s functionality and quality of life. Front Psychiatry. 2020;11:510. https://doi.org/10.3389/fpsyt.2020.00510
Strejilevich S, Szmulewicz A, Igoa A, Marengo E, Caravotta P, Martino D. Episodic density, subsyndromic symptoms, and mood instability in late-life bipolar disorders: a 5-year follow-up study. Int J Geriatr Psychiatry. 2019;34(7):950-6. https://doi.org/10.1002/gps.5094
Miller MD, Paradis CF, Houck PR, Mazumdar S, Stack JA, Rifai AH, et al. Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale. Psychiatry Res. 1992;41(3):237-48. https://doi.org/10.1016/0165-1781(92)90005-n
Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23(1):56-62. https://doi.org/10.1136/jnnp.23.1.56
Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429-35. https://doi.org/10.1192/bjp.133.5.429
Cacilhas AA, Magalhães PVS, Ceresér KM, Walz JC, Weyne F, Rosa AR, et al. Validity of a short functioning test (FAST) in Brazilian outpatients with bipolar disorder. Value Health. 2009;12(4):624-7. https://doi.org/10.1111/j.1524-4733.2008.00481.x
Rosa AR, Sánchez-Moreno J, Martínez-Aran A, Salamero M, Torrent C, Reinares M, et al. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin Pract Epidemiol Ment Health. 2007;3:5. https://doi.org/10.1186/1745-0179-3-5
Bonnín CM, Martínez-Arán A, Reinares M, Valentí M, Solé B, Jiménez E, et al. Thresholds for severity, remission and recovery using the functioning assessment short test (FAST) in bipolar disorder. J Affect Disord. 2018;240:57-62. https://doi.org/10.1016/j.jad.2018.07.045
Patterson TL, Goldman S, McKibbin CL, Hughs T, Jeste DV. UCSD Performance-Based Skills Assessment: development of a new measure of everyday functioning for severely mentally ill adults. Schizophr Bull. 2001;27(2):235-45. https://doi.org/10.1093/oxfordjournals.schbul.a006870
Mantovani LM, Machado-de-Sousa JP, Salgado JV. UCSD Performance-Based Skills Assessment (UPSA): validation of a Brazilian version in patients with schizophrenia. Schizophr Res Cogn. 2015;2(1):20-5. https://doi.org/10.1016/j.scog.2014.12.002
Brucki SMD, Nitrini R, Caramelli PHF, Bertolucci PH, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr. 2003;61(3B):777-81. https://doi.org/10.1590/s0004-282x2003000500014
Keefe RSE, Fox KH, Davis VG, Kennel C, Walker TM, Burdick KE, et al. The Brief Assessment of Cognition In Affective Disorders (BAC-A): performance of patients with bipolar depression and healthy controls. J Affect Disord. 2014;166:86-92. https://doi.org/10.1016/j.jad.2014.05.002
Barbosa IG, Ferreira RA, Rocha NP, Mol GC, Leite FMC, Bauer IE, et al. Predictors of cognitive performance in bipolar disorder: the role of educational degree and inflammatory markers. J Psychiatr Res. 2018;106:31-7. https://doi.org/10.1016/j.jpsychires.2018.09.003
Araújo GE, Resende CB, Cardoso ACA, Teixeira AL, Keefe RS, Salgado JV. Validity and reliability of the Brazilian Portuguese version of the BACS (Brief Assessment of Cognition in Schizophrenia). Clinics (Sao Paulo). 2015;70(4):278-82. https://doi.org/10.6061/clinics/2015(04)10
Depp CA, Mausbach BT, Eyler LT, Palmer BW, Cain AE, Lebowitz BD, et al. Performance-based and subjective measures of functioning in middle-aged and older adults with bipolar disorder. J Nerv Ment Dis. 2009;197(7):471-5. https://doi.org/10.1097/NMD.0b013e3181ab5c9b
Henry BL, Minassian A, Perry W. Everyday functional ability across different phases of bipolar disorder. Psychiatry Res. 2013;210(3):850-6. https://doi.org/10.1016/j.psychres.2013.04.006
Solé B, Bonnin CM, Jiménez E, Torrent C, Torres I, Varo C, et al. Heterogeneity of functional outcomes in patients with bipolar disorder: a cluster-analytic approach. Acta Psychiatr Scand. 2018;137(6):516-27. https://doi.org/10.1111/acps.12871
Watson M, Filia K, Stevens A, Cotton S, Nelson B, Ratheesh A. A systematic review and meta-analysis of global and social functioning among people at risk of bipolar disorder. J Affect Disord. 2023;321:290-303. https://doi.org/10.1016/j.jad.2022.10.019
Mantovani LM, Machado-de-Sousa JP, Salgado JV. UCSD Performance-Based Skills Assessment (UPSA): validation of a Brazilian version in patients with schizophrenia. Schizophr Res Cogn. 2015;2(1):20-5. https://doi.org/j.scog.2014.12.00
Brown MA, Velligan DI. Issues and developments related to assessing function in serious mental illness. Dialogues Clin Neurosci. 2016;18(2):135-44. https://doi.org/10.31887/DCNS.2016.18.2/dvelligan
Burdick KE, Millett CE, Yocum AK, Altimus CM, Andreassen OA, Aubin V, et al. Predictors of functional impairment in bipolar disorder: results from 13 cohorts from seven countries by the Global Bipolar Cohort Collaborative. Focus (Am Psychiatr Publ). 2023;21(4):444-52. https://doi.org/10.1176/appi.focus.23021021
Shin JK, Kim KW, Park JH, Lee JJ, Huh Y, Lee SB, et al. Impacts of poor social support on general health status in community-dwelling korean elderly: the results from the korean longitudinal study on health and aging. Psychiatry Investig. 2008;5(3):155-62. https://doi.org/10.4306/pi.2008.5.3.155
Tsoutsoulas C, Mulsant BH, Kalache SM, Kumar S, Ghazala Z, Voineskos AN, et al. The influence of medical burden severity and cognition on functional competence in older community-dwelling individuals with schizophrenia. Schizophr Res. 2016;170(2-3):330-5. https://doi.org/10.1016/j.schres.2015.12.009
Teixeira AL, Almeida OP, Lavin P, Barbosa IG, Alda M Altinbas K, et al. Physical comorbidities of older age bipolar disorder (OABD) patients: a global replication analysis of prevalence and sex differences. Gen Hosp Psychiatry. 2024;90:6-11. https://doi.org/10.1016/j.genhosppsych.2024.06.004
Blanken MAJT, Oudega ML, Almeida OP, Schouws SNTM, Orhan M, Beunders AJM, et al. Sex differences among older adults with bipolar disorder: results from the Global Aging & Geriatric Experiments in Bipolar Disorder (GAGE-BD) project. Am J Geriatr Psychiatry. 2024;32(3):326-38. https://doi.org/10.1016/j.jagp.2023.10.008
Anton SD, Woods AJ, Ashizawa T, Barb D, Buford TW, Carter CS, et al. Successful aging: advancing the science of physical independence in older adults. Ageing Res Rev. 2015;24(Pt B):304-27. https://doi.org/10.1016/j.arr.2015.09.005
Baune BT, Malhi GS. A review on the impact of cognitive dysfunction on social, occupational, and general functional outcomes in bipolar disorder. Bipolar Disord. 2015;17(Suppl 2):41-55. https://doi.org/10.1111/bdi.12341
Sletved KSO, Maiggaard K, Thorup AAE, Kessing LV, Vinberg M. Familial load of psychiatric disorders and overall functioning in patients newly diagnosed with bipolar disorder and their unaffected first-degree relatives. Int J Bipolar Disord. 2022;10(1):28. https://doi.org/10.1186/s40345-022-00277-1
Jiménez-López E, Villanueva-Romero CM, Sánchez-Morla EM, Martínez-Vizcaíno V, Ortiz M, Rodriguez-Jimenez R, et al. Neurocognition, functional outcome, and quality of life in remitted and non-remitted schizophrenia: a comparison with euthymic bipolar I disorder and a control group. Schizophr Res. 2022;240:81-91. https://doi.org/10.1016/j.schres.2021.12.038
Ernst Kretschmer (1888-1964) body and mind. JAMA. 1968;205(13):929-30. PMID: 4877024.
Maina G, Salvi V, Vitalucci A, D’Ambrosio V, Bogetto F. Prevalence and correlates of overweight in drug-naïve patients with bipolar disorder. J Affect Disord. 2008;110(1-2):149-55. https://doi.org/10.1016/j.jad.2007.12.233
Notes
Notes
Funding: This study was partially funded by FAPEMIG (Fundação de Amparo a Pesquisa de Minas Gerais) - Grant APQ-02313-18. ALT is supported by the Brazilian National Council for Scientific and Technological Development (CNPq – Bolsa de Produtividade em Pesquisa).
Conflict of interest declaration
Disclosure: The authors report no conflicts of interest.
Author notes
This study was conducted by Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
Editor-in-Chief: Sonia M. D. Brucki.
Associate Editor: Karolina Cesar Freitas.
Correspondence: Izabela Guimarães Barbosa; Email:
izabelagb@gmail.com.
