, Volume 23, Issue 6, pp 583–594

Bipolar disorder and health-related quality of life

Review of burden of disease and clinical trials
  • Dennis A. Revicki
  • Louis S. Matza
  • Emuella Flood
  • Andrew Lloyd
Review Article


Bipolar disorder is a chronic psychiatric disorder with a variable course and significant impact on patients’ social, occupational, and general functioning and wellbeing. Although there are effective pharmaceutical and psychosocial interventions for patients with bipolar disorder, many patients receive poor-quality care. Prospective longitudinal studies demonstrate that less than half of bipolar disorder patients have a good long-term response to treatment, long-term outcome is highly variable, and many patients do not fully recover. There is substantial evidence that bipolar disorder is associated with significant impairment to functioning and wellbeing.

However, few clinical trials comparing treatments for bipolar disorder have incorporated health-related quality-of-life (HR-QOL) assessments. Existing studies suggest that, while treatment improves HR-QOL, there is limited evidence for differences between the mood stabilisers in terms of HR-QOL outcomes. Additional clinical trials are needed to evaluate patient-reported outcomes associated with the most frequently used pharmacological treatments to determine whether there are meaningful differences between treatments.

There are challenges in measuring HR-QOL in patients with acute mania, and future studies should assess the psychometric qualities of HR-QOL instruments in these and other bipolar disorder patients. HR-QOL outcome data may be useful in informing psychiatrists, patients and patient family members of the effects of treatment for bipolar disorder on patients’ everyday lives, functioning and wellbeing.


  1. 1.
    Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA 1996 Jul 24–31; 276 (4): 293–9PubMedCrossRefGoogle Scholar
  2. 2.
    Bebbington P, Ramana R. The epidemiology of bipolar affective disorder. Soc Psychiatry Psychiatr Epidemiol 1995 Nov; 30 (6): 279–92PubMedCrossRefGoogle Scholar
  3. 3.
    Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry Jan 1994; 51 (1): 8–19CrossRefGoogle Scholar
  4. 4.
    Kessler RC, Rubinow DR, Holmes C, et al. The epidemiology of DSM-III-R bipolar I disorder in a general population survey. Psychol Med 1997 Sep; 27 (5): 1079–89PubMedCrossRefGoogle Scholar
  5. 5.
    Wyatt RJ, Henter I, Leary MC, et al. An economic evaluation of manic-depressive illness: 1991. Soc Psychiatry Psychiatr Epidemiol 1995 Aug; 30 (5): 213–9PubMedGoogle Scholar
  6. 6.
    Simon GE, Unutzer J. Health care utilization and costs among patients treated for bipolar disorder in an insured population. Psychiatr Serv 1999 Oct; 50 (10): 1303–8PubMedGoogle Scholar
  7. 7.
    World Health Organization. The world health report, 1999. Geneva: World Health Organization, 1999Google Scholar
  8. 8.
    Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990Google Scholar
  9. 9.
    Dion GL, Tohen M, Anthony WA, et al. Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hosp Community Psychiatry 1988 Jun; 39 (6: 652–7PubMedGoogle Scholar
  10. 10.
    Coryell W, Scheftner W, Keller M, et al. The enduring psychosocial consequences of mania and depression. Am J Psychiatry 1993 May; 150 (5): 720–7PubMedGoogle Scholar
  11. 11.
    Leidy NK, Palmer C, Murray M, et al. Health-related quality of life assessment in euthymic and depressed patients with bipolar disorder: psychometric performance of four self-report measures. J Affect Disord 1998 Mar; 48 (2-3): 207–14PubMedCrossRefGoogle Scholar
  12. 12.
    Keck Jr PE, McElroy SL, Strakowski SM, et al. 12-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. Am J Psychiatry 1998 May; 155 (5): 646–52PubMedGoogle Scholar
  13. 13.
    Patrick DL, Chiang YP. Measurement of health outcomes in treatment effectiveness evaluations: conceptual and methodological challenges. Med Care 2000 Sep; 38 (9 Suppl.): II14–25PubMedGoogle Scholar
  14. 14.
    Leidy NK, Revicki DA, Geneste B. Recommendations for evaluating the validity of quality of life claims for labeling and promotion. Value Health 1999; 2 (2): 113–27PubMedCrossRefGoogle Scholar
  15. 15.
    Young RC, Biggs IT, Ziegler VE, et al. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978 Nov; 133: 429–35PubMedCrossRefGoogle Scholar
  16. 16.
    Suppes T, Dennehy EB, Swann AC, et al. Report of the Texas Consensus Conference Panel on medication treatment of bipolar disorder 2000. J Clin Psychiatry 2002 Apr; 63 (4): 288–99PubMedCrossRefGoogle Scholar
  17. 17.
    American Psychiatric Association. Practice guidelines for the treatment of patients with bipolar disorder. Am J Psychiatry 1994; 151 (12 Suppl.): S1–S36Google Scholar
  18. 18.
    Pope Jr HG, McElroy SL, Keck Jr PE, et al. Valproate in the treatment of acute mania: a placebo-controlled study. Arch Gen Psychiatry 1991 Jan; 48 (1): 62–8PubMedCrossRefGoogle Scholar
  19. 19.
    Freeman TW, Clothier JL, Pazzaglia P, et al. A double-blind comparison of valproate and lithium in the treatment of acute mania. Am J Psychiatry Jan 1992; 149 (1): 108–11Google Scholar
  20. 20.
    Bowden CL. Efficacy of lithium in mania and maintenance therapy of bipolar disorder. J Clin Psychiatry 2000; 61 Suppl. 9: 35–40PubMedGoogle Scholar
  21. 21.
    Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. JAMA 1994 Mar 23–30; 271 (12): 918–24PubMedCrossRefGoogle Scholar
  22. 22.
    Bowden CL, Calabrese JR, McElroy SL, et al. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Divalproex Maintenance Study Group. Arch Gen Psychiatry 2000 May; 57 (5): 481–9PubMedCrossRefGoogle Scholar
  23. 23.
    Tohen M, Sanger TM, McElroy SL, et al. Olanzapine versus placebo in the treatment of acute mania. Olanzapine HGEH Study Group. Am J Psychiatry May 1999; 156 (5): 702–9Google Scholar
  24. 24.
    Tohen M, Jacobs TG, Grundy SL, et al. Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. The Olanzipine HGGW Study Group. Arch Gen Psychiatry 2000 Sep; 57 (9): 841–9PubMedCrossRefGoogle Scholar
  25. 25.
    Tohen M, Watemaux CM, Tsuang MT. Outcome in mania: a 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry 1990 Dec; 47 (12): 1106–11PubMedCrossRefGoogle Scholar
  26. 26.
    Goldberg IF, Harrow M, Grossman LS. Course and outcome in bipolar affective disorder: a longitudinal follow-up study. Am J Psychiatry 1995 Mar; 152 (3): 379–84PubMedGoogle Scholar
  27. 27.
    Gitlin MJ, Swendsen J, Heller TL, et al. Relapse and impairment in bipolar disorder. Am J Psychiatry 1995 Nov; 152 (11): 1635–40PubMedGoogle Scholar
  28. 28.
    Keller MB, Lavori PW, Coryell W, et al. Bipolar I: a five-year prospective follow-up. J Nerv Ment Dis 1993 Apr; 181 (4): 238–45PubMedCrossRefGoogle Scholar
  29. 29.
    Coryell W, Turvey C, Endicott J, et al. Bipolar I affective disorder: predictors of outcome after 15 years. J Affect Disord 1998 Sep; 50 (2-3): 109–16PubMedCrossRefGoogle Scholar
  30. 30.
    Suppes T, Dennehy EB, Gibbons EW. The longitudinal course of bipolar disorder. J Clin Psychiatry 2000; 61 Suppl. 9: 23–30PubMedGoogle Scholar
  31. 31.
    Namjoshi MA, Buesching DP. A review of the health-related quality of life literature in bipolar disorder. Qual Life Res 2001; 10 (2): 105–15PubMedCrossRefGoogle Scholar
  32. 32.
    Shi L, Namjoshi MA, Zhang F, et al. Olanzapine versus haloperidol in the treatment of acute mania: clinical outcomes, healthrelated quality of life and work status. Int Clin Psychopharmacol Sep 2002; 17 (5): 227–37CrossRefGoogle Scholar
  33. 33.
    Namjoshi MA, Rajamannar G, Jacobs T, et al. Economic, clinical, and quality-of-life outcomes associated with olanzapine treatment in mania: results from a randomized controlled trial. J Affect Disord 2002 May; 69 (1-3): 109–18PubMedCrossRefGoogle Scholar
  34. 34.
    Revicki DA, Paramore LC, Sommerville KW, et al. Divalproex sodium versus olanzapine in the treatment of acute mania in bipolar disorder: health-related quality of life and medical cost outcomes. J Clin Psychiatry 2003 Mar; 64 (3): 288–94PubMedCrossRefGoogle Scholar
  35. 35.
    Atkinson M, Zibin S, Chuang H. Characterizing quality of life among patients with chronic mental illness: a critical examination of the self-report methodology. Am J Psychiatry 1997 Jan; 154 (1): 99–105PubMedGoogle Scholar
  36. 36.
    Awad AG, Voruganti LN, Heslegrave RJ. Measuring quality of life in patients with schizophrenia. Pharmacoeconomics 1997 Jan; 11 (1): 32–47PubMedCrossRefGoogle Scholar
  37. 37.
    Cramer J, Rosenheck R, Xu W, et al. Detecting improvement in quality of life and symptomatology in schizophrenia. Schizophr Bull 2001; 27 (2): 227–34PubMedCrossRefGoogle Scholar
  38. 38.
    Revicki DA, Tohen M, Gyulai L, et al. Telephone versus inperson clinical and health status assessment interviews in patients with bipolar disorder. Harv Rev Psychiatry 1997 Jul-Aug; 5 (2): 75–81PubMedCrossRefGoogle Scholar
  39. 39.
    Pedersen RD, Pallay AG, Rudolph RL. Can improvement in well-being and functioning be distinguished from depression improvement in antidepressant clinical trials? Qual Life Res 2002 Feb; 11 (1): 9–17PubMedCrossRefGoogle Scholar
  40. 40.
    Patrick DL, Erickson P. Health status and health policy: quality of life in health care evaluation and resource allocation. New York: Oxford University Press, 1993Google Scholar
  41. 41.
    Revicki DA, Osoba D, Fairclough D, et al. Recommendations on health-related quality of life research to support labeling and promotional claims in the United States. Qual Life Res 2000; 9 (8): 887–900PubMedCrossRefGoogle Scholar
  42. 42.
    Ware JE, Snow KK, Kosinski MK, et al. SF-36 Health Survey: manual and interpretation guide. Boston (MA): The Health Institute, New England Medical Center, 1993Google Scholar
  43. 43.
    Ware Jr J, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care Mar 1996; 34 (3): 220–33CrossRefGoogle Scholar
  44. 44.
    Stewart AL, Ware JE, editors. Measuring functioning and wellbeing: the medical outcomes study approach. Durham (NC): Duke University Press, 1992Google Scholar
  45. 45.
    Endicott J, Nee J, Harrison W, et al. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure. Psychopharmacol Bull 1993; 29 (2): 321–6PubMedGoogle Scholar
  46. 46.
    Pradhan SC, Sinha VK, Sinhh TB. Psycho-social dysfunctions in patients after recovery from mania and depression. Int J Rehabil Res 1999 Dec; 22 (4): 303–9PubMedCrossRefGoogle Scholar
  47. 47.
    Robb JC, Cooke RG, Devins GM, et al. Quality of life and lifestyle disruption in euthymic bipolar disorder. J Psychiatr Res 1997 Sep-Oct; 31 (5): 509–17PubMedCrossRefGoogle Scholar
  48. 48.
    Dupuy HJ. The Psychological General Well-Being (PGWB) Index. In: Wenger NK, Mattson ME, Furberg CD, et al., editors. Assessment of quality of life in clinical trials of cardiovascular therapies. Washington, DC: Le Jacq Publishing, 1984: 170–83Google Scholar
  49. 49.
    Stoker MJ, Dunbar GC, Beaumont G. The SmithKline Beecham `Quality of Life’ scale: a validation and reliability study in patients with affective disorder. Qual Life Res 1992 Dec; 1 (6): 385–95PubMedCrossRefGoogle Scholar
  50. 50.
    Dausch BM, Miklowitz DJ, Richards JA. Global Assessment of Relational Functioning Scale (GARF): II. Reliability and validity in a sample of families of bipolar patients. Fam Process 1996 Jun; 35 (2): 175–89PubMedCrossRefGoogle Scholar
  51. 51.
    Stewart AL, Ware JE, Sherbourne CD, et al. Psychological distress/well-being and cognitive functioning measures. In: Stewart AL, Ware JE, editors. Measuring functioning and well-being: the medical outcomes study approach. Durham (NC): Duke University Press, 1992Google Scholar
  52. 52.
    Hunt SM, McKenna SP. The QLDS: a scale for the measurement of quality of life in depression. Health Policy 1992 Oct; 22 (3): 307–19PubMedCrossRefGoogle Scholar
  53. 53.
    McKenna SP, Hunt SM. A new measure of quality of life in depression: testing the reliability and construct validity of the QLDS. Health Policy 1992 Oct; 22 (3): 321–30PubMedCrossRefGoogle Scholar
  54. 54.
    Kind P. The EuroQol instrument: an index of health-related quality of life. In: Spilker B, editor. Quality of life and pharmacoeconomics in clinical trials. 2nd ed. Philadelphia (PA): Lippincott-Raven Publishers, 1996: 191–201Google Scholar
  55. 55.
    Ferrans CE, Powers MI. Psychometric assessment of the Quality of Life Index. Res Nurs Health 1992 Feb; 15 (1): 29–38PubMedCrossRefGoogle Scholar
  56. 56.
    Lehman AF. The effects of psychiatric symptoms on quality of life assessments among the chronic mentally ill. Eval Program Plann 1983; 6 (2): 143–51PubMedCrossRefGoogle Scholar
  57. 57.
    Bech P. Rating scales for psychopathology, health status, and quality of life: a compendium on documentation in accordance with the DSM-III and WHO systems. Berlin: Springer, 1993CrossRefGoogle Scholar
  58. 58.
    Keller MB, Lavori PW, Friedman B, et al. The longitudinal interval follow-up evaluation: a comprehensive method for assessing outcome in prospective longitudinal studies. Arch Gen Psychiatry 1987 Jun; 44 (6: 540–8PubMedCrossRefGoogle Scholar
  59. 59.
    Russo J, Roy-Byme P, Reeder D, et al. Longitudinal assessment of quality of life in acute psychiatric inpatients: reliability and validity. J Nerv Ment Dis 1997 Mar; 185 (3): 166–75PubMedCrossRefGoogle Scholar
  60. 60.
    Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care 1989 Mar; 27 (3 Suppl.): S217–32PubMedCrossRefGoogle Scholar
  61. 61.
    Abood Z, Sharkey A, Webb M, et al. Are patients with bipolar affective disorder socially disadvantaged? A comparison with a control group. Bipolar Disord 2002 Aug; 4 (4): 243–8PubMedCrossRefGoogle Scholar
  62. 62.
    Lish JD, Dime-Meenan S, Whybrow PC, et al. The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord 1994 Aug; 31 (4): 281–94PubMedCrossRefGoogle Scholar
  63. 63.
    Cooke RG, Robb JC, Young LT, et al. Well-being and functioning in patients with bipolar disorder assessed using the MOS 20-Item Short Form (SF-20). J Affect Disord 1996 Jul 8; 39 (2): 93–7PubMedCrossRefGoogle Scholar
  64. 64.
    Robb JC, Young LT, Cooke RG, et al. Gender differences in patients with bipolar disorder influence outcome in the medical outcomes survey (SF-20) subscale scores. J Affect Disord 1998 Jun; 49 (3): 189–93PubMedCrossRefGoogle Scholar
  65. 65.
    MacQueen GM, Young LT, Robb JC, et al. Levels of functioning and well-being in recovered psychotic versus nonpsychotic mania. J Affect Disord 1997 Oct; 46 (1): 69–72PubMedCrossRefGoogle Scholar
  66. 66.
    Arnold LM, Witzeman KA, Swank ML, et al. Health-related quality of life using the SF-36 in patients with bipolar disorder compared with patients with chronic back pain and the general population. J Affect Disord 2000 Jan-Mar; 57 (1-3): 235–9PubMedCrossRefGoogle Scholar
  67. 67.
    Vojta C, Kinosian B, Glick H, et al. Self-reported quality of life across mood states in bipolar disorder. Compr Psychiatry 2001 May-Jun; 42 (3): 190–5PubMedCrossRefGoogle Scholar
  68. 68.
    Ozer S, Ulusahin A, Batur S, et al. Outcome measures of interepisode bipolar patients in a Turkish sample. Soc Psychiatry Psychiatr Epidemiol 2002 Jan; 37 (1): 31–7PubMedCrossRefGoogle Scholar
  69. 69.
    Revicki DA, Hirschfeld RM, Keck PE, et al. Cost-effectiveness of divalproex long-term therapy for bipolar disorder [abstract]. Washington, DC: Challenges for the 21st Century: Mental Health Services Research, 2000 JulGoogle Scholar
  70. 70.
    Hanlon J, Mannix S, Kleinman L, et al. Patient-valued health state utilities for bipolar disorder: differences that can be measured [abstract]. International Society for Pharmacoeconomics and Outcomes Research; 2003 May 1821, Arlington (VA)Google Scholar
  71. 71.
    Tsevat J, Keck PE, Homung RW, et al. Health values of patients with bipolar disorder. Qual Life Res 2000; 9 (5): 579–86PubMedCrossRefGoogle Scholar
  72. 72.
    Tohen M, Stoll AL, Strakowski SM, et al. The McLean FirstEpisode Psychosis Project: six-month recovery and recurrence outcome. Schizophr Bull 1992; 18 (2): 273–82PubMedCrossRefGoogle Scholar
  73. 73.
    Frank E, Prien RF, Jarrett RB, et al. Conceptualization and rationale for consensus definitions of terms in major depressive disorder: remission, recovery, relapse, and recurrence. Arch Gen Psychiatry 1991 Sep; 48 (9): 851–5PubMedCrossRefGoogle Scholar
  74. 74.
    Strakowski SM, Keck Jr PE, McElroy SL, et al. Twelve-month outcome after a first hospitalization for affective psychosis. Arch Gen Psychiatry 1998 Jan; 55 (1): 49–55PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  • Dennis A. Revicki
    • 1
  • Louis S. Matza
    • 1
  • Emuella Flood
    • 1
  • Andrew Lloyd
    • 1
  1. 1.Center for Health Outcomes ResearchThe MEDTAP Institute at United BioSource CorporationBethesdaUSA

Personalised recommendations