Level of functioning among Bipolar Disorder Patients

Level of Functioning among the Bipolar Affective Disorder patients Abstract: Bipolar Affective disorder (BPAD) is a lifelong psychiatric disorder which may carry severe impairment of patients’ general functioning. An exploratory study was conducted to assess the level of functioning of bipolar affective disorder patients attending psychiatric setting in CMC & H and DMC & H, Ludhiana. Data was collected for 60 bipolar affective disorder patients from their significant relatives. Level of functioning was assessed by using rating scale in the month of November & December, 2009. Findings revealed that overall level of functioning of BPAD patients was moderate. Deficit areas in the functioning of the BPAD patients were found to be nail care, house keeping, occupation, eating, money management & shopping skills, interactional skills and spending leisure time. Objective To assess the level of functioning of BPAD patients attending psychiatric setting To assess the deficit areas in level of functioning in BPAD patients Materials and Methods The study was conducted in psychiatric OPD & ward of Christian Medical College & Hospital and Dayanand Medical College & Hospital, Ludhiana, Punjab. Sixty BPAD patients were taken through purposive sampling technique. Eleven areas of functioning were assessed by using a rating scale. Result Among the BPAD patients, 75% were having moderate level of functioning, 22% were having high level of functioning and 3% were having low level of functioning. Majority of the patients were having moderate level of functioning in the areas of brushing teeth (55%), hair care (55%), nail care (62%). Money management and shopping skills (55%) and spending leisure time (70%). The deficit areas where majority of the bipolar affective disorder patients(56%) showed low level of functioning is house keeping/ occupation. Conclusion The areas of nail care, house keeping / occupation, eating, money management and shopping skills, interactional skills and spending leisure time were found to be the deficit areas in the functioning of Bipolar Affective Disorder Patients. Overall level of functioning of the bipolar affective disorder patients was moderate (57%). Key Words BPAD (Bipolar Affective Disorder), Level of functioning, Deficit areas. Introduction Bipolar Affective disorder is viewed as one of the disabling affliction that can affect various aspects of individual’s functioning. Patients develop severe level of incapacity in every sphere of life functioning, starting from personal and social skills, daily living, health and hygiene, self care, occupational or vocational abilities and cognitive abilities. Although the severity of mood episodes is the major determinant of patient’s ability to work or have relationships, many patients experience functional impairments, even during euthymic periods. Affective disorders are often life long illnesses that produce considerable personal, marital, familial, scholastic and occupational disturbances. Bipolar by nature is a recurrent illness and even when the patients are protected by pharmacotherapy about 40% relapse is in 1 year, 60% in 2 years and 73% over 5 years.1 It is a serious life long struggle and challenge which lead to severe impairment of function. Affective disorders carry with them substantial societal burden through high social costs related to health care and morbidity as many as 35% to 60% of persons with bipolar disorder have poor clinical outcomes2 and social, family and occupational dysfunction is the norm.3 Without treatment, a person with bipolar disorder at the age of 25 can expect the loss of 14 years of role functioning and 9 years of life.4 The 2002 APA Practice Guideline for the treatment of patients with bipolar disorder defines remission during acute phase of treatment as “ a complete return to baseline level of functioning and a virtual lack of symptoms.” The ability to function involves more than presence or absence of symptoms as some patients with bipolar disorder function well despite having severe symptoms but can be dysfunctional. Monitoring response to treatment should extend beyond symptom reduction to include a focus on a person’s improvement in level of functioning. 5 A primary nursing concern for the clients with mood disorders is physiologic integrity and function. Often these clients avoid eating, have difficulty sleeping, and suffer from other physiologic consequences of their inability to engage in self care. The client with depression lacks energy or interest ; the client with mania cannot focus long enough to complete simple tasks. 6 According to DSM- IV TR, the diagnosis of BPAD is made if along with symptoms, client is also having significant impairment in the social, personal or occupational functioning. In India, there are very few studies that address the functional levels of the patients suffering from BPAD. So the need was felt to focus on the level of functioning of these patients. Moreover, identifying the deficit areas in functioning of these patients can help in preparing guidelines based on their identified deficit areas for the BPAD patients to improve rehabilitation. Materials and Methods The study was conducted in psychiatric OPD & ward of Christian Medical College & Hospital and Dayanand Medical College & Hospital, Ludhiana, Punjab.Data collection was carried out from 9th Nov. to 24th Dec. 2009. Target population was BPAD patients admitted in psychiatric ward or attending OPDs in CMC & H and DMC & H. Purposive sampling technique was used. Sample size was 60. After extensive review of literature, researcher prepared rating scale to assess the level of functioning consisting of 60 items categorized under 11 areas of functioning- Bathing, Dressing, Elimination, Brushing teeth, Hair care, Nail care, House keeping/Occupation, Eating, Money management and shopping skills, Interactional skills and Spending leisure time. The possible range of scores varied from 0 (minimum) to 120 (maximum). This helped the researcher to categorize the functioning under three levels i.e. High level of functioning (score ≥81), Moderate level of functioning (score 41-80), Low level of functioning (score ≤40). The reliability of the tool was computed by Split Half Technique and was calculated by Spearman Brown Prophecy formula. The calculated r was 0.989. So the tool was reliable. Content validity of the tool was established by seeking the opinion of guide, co-guide and experts from various nursing specialties. Modifications in the tool were made according to the suggestion and the guidance. Pilot study was conducted in the month of October, 2009. Analysis and interpretation of data was done by using descriptive and inferential statistics such as mean, mean percentage, SD, ‘t’ value and ANOVA. Results Table 1. Mean, Mean percentage and Rank order of Level of Functioning among BPAD patients Areas of functioning   Maximum Score Mean Score Mean % Score Rank Bathing   8 5.7 71 5 Dressing   16 11.5 72 3.5 Elimination   12 9.53 79 1 Brushing Teeth   10 7.22 72 3.5 Hair care   4 2.93 73 2 Nail care   4 2.13 53 7 House keeping/occupation   12 3.5 29 11 Eating   18 9.8 54 6 Money management & shopping skills 16 6.98 44 9 Interactional skills   8 4.05 51 8 Spending leisure time   12 5.13 43 10 Total level of functioning   120 68.5 57 Table 1 shows the mean and mean percentage of the level of functioning of bipolar affective disorder patients. Higher the mean % age, higher is the level of functioning and vice versa. The mean score of overall functioning in all areas of functioning was 68.5 and the total mean percentage was 57%. The mean percentage in the area of elimination was 79% followed by hair care (73%), brushing teeth and dressing (72% each). Area of bathing was having mean percentage of 71% followed by mean percentage of eating (54%), nail care (53%) and interactional skills (51%). Areas of money management and shopping skills, spending leisure time and house keeping/occupation were having mean percentage of level of functioning as 44%, 43% and 29% respectively. As evident from the table 1 overall level of functioning of the bipolar affective disorder patients was moderate. The areas of nail care, house keeping / occupation, eating, money management, shopping skills, interactional skills and spending leisure time were the deficit areas in level of functioning of Bipolar Affective Disorder Patients. Table 2. Percentage Distribution According to the Level of functioning in Different Areas Among the BPAD Patients N=60   Level of Functioning Areas of functioning Total Score High Moderate Low n % Score range n % Score range n % Score range Bathing 8 37 62 >5 21 35 3-5 2 3 <3 Dressing 16  31 52 >11 26 43 5-11 3 5 <5 Elimination 10  42 70 >8 13 22 4-8 5 8 <4 Brushing Teeth 12  26 43 >7 33 55 4-7 1 2 <4 Hair care 4  24 40 >3 33 55 2-3 3 5 <2 Nail care 4  9 15 >3 37 62 2-3 14 23 <2 House keeping/occupation 12  4 7 >8 22 37 4-8 34 56 <4 Eating 18  20 33 >12 26 43 6-12 14 24 <6 Money management & shopping skills 16  9 15 >11 33 55 5-11 18 30 <5 Interactional skills 8  15 25 >5 27 45 3-5 18 30 <3 Spending leisure time 12  5 8 >8 42 70 4-8 13 22 <4 Total Level of Functioning 120 13 22 >80 45 75 41-80 2 3 <40 Table 2 depicts that in the area of bathing, 62% of the bipolar affective disorder patients had high, 21% moderate and just 3% had low level of functioning. In the area of dressing, 52% were having high, 43% moderate and only 5% were having low level of functioning. Regarding the area of elimination, 70% were having high level whereas 22% had moderate and 8% had low level of functioning. 43% of the patients were having high level, 55% moderate and only 2% were having low level of functioning in the area of brushing teeth. Majority (62%) of the patients were having moderate level of functioning in the area of nail care followed by 23% having low level and 16% having high level of functioning in this area. In the area of house keeping/occupation, 56% of the patients were having low level of functioning whereas 37% having moderate and 7% having high level of functioning. In the area of eating 33% were having high level. 43% moderate and 24% low level of functioning. Regarding money management and shopping skills. 55 % were having moderate level, 30% were having low level and 15% were having high level of functioning. 45% were having moderate 30% were having low and 25% were having low level of functioning in the area of interactional skills. In the area of spending leisure time, maximum (70%) were having moderate level, 22% having low level and just 8% having high level of functioning respectively. Regarding total level of functioning, 75% of the patients were having moderate level of functioning, 22% were having high level of functioning and 3% were having low level of functioning. Hence, it can be concluded that majority of the patients were having moderate level of functioning in the areas of brushing teeth, hair care, nail care, money management shopping skills and spending leisure time. The deficit areas where majority of the bipolar affective disorder patients (56%) showed low level of functioning was house keeping/ occupation. Discussion Bipolar Disorder is a common, chronic and severe mental disorder, affecting approximately 2% of the adult population. Bipolar Disorder causes substantial functional impairment that frequently affects the patient’s marriage, children, occupation, and other aspects of patient’s life. The findings of the study also revealed that the areas of nail care (53%), house keeping / occupation (29%), eating (54%), money management and shopping skills (44%), interactional skills (51%) and spending leisure time (43%) were the deficit areas in the functioning of Bipolar Affective Disorder Patients. Overall level of functioning of the bipolar affective disorder patients is moderate (57%). These findings are in agreement with the various studies A.R. Rosa et al. 7 assessed the Functional Impairment in Patients with Remitted Bipolar Disorder. A moderate impact was observed in the interpersonal relationships, and the weakest effect was found in the financial issue and leisure time domains. Taking care of their household, living alone, independence and taking their medication were the most frequent difficulties in the autonomy domain. They were also experiencing some degree of difficulty in handling money. Moreno J. Sanchez et al. 8 studied the functional impairment in bipolar disorder patients. It suggested low functioning in bipolar patients even when they are in clinical remission. Frederick K. Goodwin & S.Nassir Ghaemi 9 studied the course of bipolar disorder which revealed that in good prognosis cohort, fewer patients (72%) achieved full symptomatic recovery (i.e. were in complete remission), and even fewer achieved functional recovery (43%). Judd L. Lewis et al. (2003)10 compared psychosocial disability and work role function which shows that patients with mood disorders experienced some degree of disability during the majority of long term follow-up (54 to 59% of months), including 19 to 23% of months with moderate and 7 to 9% of months with severe overall impairment. Keck et al. (1998)3 revealed that many patients have great difficulty returning to their previous level of functioning after experiencing an affective episode, and recurrent episodes can lead to permanent disability. Arnold at al. 11 found that patients with bipolar disorder (mood state not specified) reported significant impairment on almost all scales of the SF-36 functional status questionnaire compared with the general population norm. Soreff Stephen & Mclennes Lynne Alison12 stated that persons experiencing a depressed episode demonstrate poor personal hygiene of individuals .They have not paid attention to their hair, exhibit dirty fingernails and hands. In manic episode, patients clothes have been put on in haste and are disorganized. George L Dion Sc.D. et al. 13 studied the relationship between symptoms and functioning of patients with bipolar disorder who were hospitalized for a manic episode. Almost 80 percent of patients were symptom free or mildly symptomatic. However, only 43 percent of patients were employed, and only 21 percent were working at their expected level of employment. Thirty percent were rated as being unable to work. Tohen et al. 14 evaluated life with mania in 166 manic patients 2 years after hospitalization. Almost all were recovered from manic and depressive syndromes and 72% were free of nearly all symptoms, but only 43% had regained their occupational functioning. Olfson et al.15 found that diagnosis of bipolar disorder was associated with a sevenfold increase in likelihood of missing work because of illness. 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