Quality Of Life And Functional Impairment

We must no longer limit ourselves to evaluating treatments by focusing on symptoms alone. In unipolar depression research and practice, the die has been cast. Treatment response, defined as 50% or more improve ment in mood symptoms, is no longer sufficient. Remission—the near complete removal of depressive symptoms—is the goal (Thase et al. 2002) because it has been shown that even mild to moderate residual symptoms are associated with continued functional impairment in patients with unipolar depressive illness (Thase 2001). Similar observations have been made with bipolar disorder (Altshuler et al. 2002). Furthermore, it has been shown that symptomatic improvement in bipolar disorder does not lead to functional improvement in all cases. In one study, despite syndromal recovery, about 40% of patients who had recovered from an initial manic episode had not achieved functional recovery (Tohen et al. 2000). Some of the continued functional impairment, even in patients with bipolar disorder who achieve euthymia, may have to do with long-term cognitive impairment (Martinez-Aran et al. 2004; van Gorp et al. 1998). Such cognitive impairment may be the consequence of excitotoxic effects of catecholamine overactivity during repeated mood episodes (Altshuler 1993; Lampe et al. 2003). Addressing cognitive impairment in persons with bipolar disorder will be an important task for researchers and clinicians. The new generation of cognitive enhancing agents may have potential in this regard.

Nevertheless, it is not entirely clear that our medications will bring us to the goal of remission. As noted above, the use of psychotherapies together with medications have not been tried with sufficient vigor. Medications are often blunt instruments in bipolar disorder, overshooting or undershooting the mark of euthymia: when one tries to achieve remission by using several medications in combination, the likelihood of increased side effects that can undermine functioning and quality of life must be carefully weighed; one should also pay careful attention to the potential of psychotherapy to improve overall functioning. Therefore, future clinical trials should focus on quality of life and functional impairment as key outcomes, and clinicians should focus on such issues, and not just symptom status, as they choose among treatments. This approach may lead to the use of fewer rather than more medications as the balance of side effects and benefits is weighed—at least until more tolerable effective medications are developed for bipolar disorder.

Bipolar Disorder Uncovered

Bipolar Disorder Uncovered

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