Research report
Subjective life satisfaction and objective functional outcome in bipolar and unipolar mood disorders: A longitudinal analysis

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Abstract

Background

Quality of life (QOL) has gained increasing attention as an important yet underappreciated component of functional outcome in mood disorders. In particular, the relationship between subjective life satisfaction and objective measures of psychosocial adjustment has not been well-studied. The goal of the present study was to examine the longitudinal associations between subjective life satisfaction and objective functional outcome among individuals with bipolar and unipolar mood disorders.

Method

One hundred fifty-seven mood disordered subjects were assessed at index hospitalization for bipolar mania (n = 35), unipolar psychotic depression (n = 27), or unipolar nonpsychotic depression (n = 95). All were prospectively followed up three times, at approximately 2, 4.5 and 7–8 years. Global outcome, work performance, social adjustment, recurrent depressive episodes, and dimensions of life satisfaction were assessed by semi-structured interviews using standardized ratings.

Results

Subjective life satisfaction strongly paralleled global functioning, work performance and social adjustment at each follow-up for patients with unipolar nonpsychotic depression, but not bipolar disorder or unipolar psychotic depression. Depressive symptoms and objective functional impairment contributed to poor QOL in most domains, independent of illness chronicity, medication use, or affective disorder subtype.

Limitations

Findings might have differed had a different QOL measure been used, although the present measure showed concurrent validity with a previously used instrument. Sample sizes for the bipolar and psychotic depression groups were sufficient to detect moderate, but not small, correlations between objective functioning and subjective QOL.

Conclusions

Recurrent depression remains a substantial contributor to poor life satisfaction across affective disorder subtypes. Subjective QOL in bipolar and unipolar psychotic depression patients may not accurately reflect objective functional outcome status, potentially due to diminished insight, demoralization, or altered life expectations over time.

Introduction

Psychiatric outcomes research has paid increasing attention to the concept of quality of life (QOL). Among individuals with primary affective disorders, depression has been associated with frequent dissatisfaction in overall social, physical and emotional well-being (Broadhead et al., 1990, Cooke et al., 1996, Lehman, 1983, Pyne et al., 1997), as well as with traditionally studied areas of occupational disability and diminished work productivity. Although recent literature has drawn attention to subjective life satisfaction in major affective disorder patients (Arfen, 1997, Atkinson, 1997, Atkinson et al., 1997), little is known about the extent to which quality of life parallels objective measures of psychosocial functioning (Atkinson, 1997, Atkinson et al., 1997, Gill and Feinstein, 1994, Leplege and Hunt, 1997). It is also unknown whether different aspects of life satisfaction (such as work versus social satisfaction) are equally affected in bipolar and unipolar mood disorders. The impact of depression relapse on individual life satisfaction domains across mood disorder subtypes also is not well understood.

QOL in patients with bipolar disorder appears poorer than in the general population (Arnold et al., 2000) or in patients with schizophrenia (Atkinson et al., 1997), and is comparable to or worse than that seen among the chronically medically ill (Arnold et al., 2000, Cooke et al., 1996, Robb et al., 1997, Robb et al., 1998). Though potentially linked with multiple depressive episodes (MacQueen et al., 2000), diminished life satisfaction in bipolar disorder persists even during periods of sustained euthymia (Cooke et al., 1996, Robb et al., 1997, Robb et al., 1998). Comparisons of life satisfaction between bipolar and unipolar mood disorders have not been extensively described. Russo et al. (1997) observed weaker inter-relationships among QOL dimensions for bipolar than unipolar patients, suggesting that life satisfaction may vary across domains among subtypes of mood disorders. Moreover, the extent to which self-report measures validly reflect life satisfaction also has been questioned in severe mood disorders (Atkinson et al., 1997).

The foregoing observations prompted us to examine satisfaction in major life areas relative to objective functional outcome in work and social roles. We further wished to assess differences between life satisfaction and depression relapse as it impacts global functioning (Goldberg et al., 1995a). Five components of life satisfaction were assessed relative to global outcome and objective measures of work and social adjustment across three successive follow-ups over 7–8 years after index hospitalization. We hypothesized that bipolar and psychotic depression patients would have poorer life satisfaction as compared to patients originally hospitalized for unipolar depression, and that subjective life satisfaction ratings would reflect objective functional outcome more strongly among nonpsychotic unipolar depression patients than in more severe (i.e., bipolar and psychotic unipolar depression) patients.

Section snippets

Subjects

We evaluated 157 relatively early young patients initially as inpatients who were then prospectively followed over a 7–8-year period. Subjects were part of the Chicago Follow-up Study, a longitudinal outcome program studying features of thought disorder, positive and negative symptoms, psychosis, affective relapse, and psychosocial outcome in a large young adult cohort initially hospitalized for psychotic and mood-related disorders (Goldberg et al., 1995a, Goldberg et al., 1995b, Goldberg et

Results

Table 1 summarizes demographic and clinical characteristics for the three diagnostic groups. Notable was the significantly greater proportion of unipolar psychotic or nonpsychotic than bipolar subjects with one or no hospitalizations prior to the index admission. As shown in Table 2, naturalistic pharmacotherapy patterns were similar across affective disorder groups with regard to antidepressant use, but use of lithium or antipsychotic medications was higher in the bipolar than unipolar groups.

Discussion

Contrary to our initial hypothesis, overall dimensions of life satisfaction did not differ significantly among bipolar or unipolar depression patients, as measured across three successive follow-ups over a 7–8-year period. However, consistent with our second hypothesis, high concordance was seen between subjective life satisfaction and objective measures of global, work and social functioning among unipolar nonpsychotic depression patients; this relationship was less strong for bipolar or

Acknowledgements

Supported in part by NIMH K-23 Career Development Award MH-01936 (JFG) and NIMH grant MH-26341 (MH), a NARSAD Young Investigator Award (JFG), and by the Stanley Bipolar Research Center of the Zucker Hillside Hospital.

The authors wish to thank Robert N. Faull, BA, for his assistance with data analyses, and Barbara Napolitano, PhD, for her assistance with statistical design and interpretation.

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