ابعاد کنترل روانشناختی والدین: ارتباطات با پرخاشگری فیزیکی و رابطه پیش دبستانی در روسیه

The aim of this study was to identify how different areas of function (role performance, interpersonal relationships, sexual activity and recreational enjoyment) differentially recover from a manic episode during the 8 months following a first psychiatric hospitalization. Fifty patients with bipolar disorder, 16–45 years of age, who met the criteria for a current manic episode were recruited during their first psychiatric hospitalization. Forty-two (84%) of these participated in follow-up. Patients were evaluated using structured and semi-structured clinical instruments and the four areas of functional outcome were assessed with the LIFE interview. Recovery of the four areas of function were compared using survival and correlational analyses. Logistic regression identified factors associated with functional outcome. The four aspects of function were not significantly intercorrelated at baseline or during follow-up. Moreover, the survival curves for the different areas of function significantly differed. Specifically, patients demonstrated better recovery of sexual activity and worse recovery of recreational enjoyment than the other areas of function. Different clinical and demographic variables predicted recovery of the different areas of function. In conclusion, following a first manic episode, recovery of psychosocial function can be divided into separate components, i.e., role function, interpersonal relationships, sexual activity and recreational enjoyment, that appear to be relatively independent. Further clarification of recovery of these different areas of function may lead to better integrated treatments that maximize functional improvement early in the course of bipolar disorder.

Most prior outcome studies of bipolar disorder have concentrated primarily or exclusively on symptom improvement, with much less attention to recovery of psychosocial function, so that this aspect of recovery is not well described (Gitlin and Hammen, 1999). Moreover, those studies that have examined functional recovery primarily focused on global measures of function, rather than examining specific, discrete areas of psychosocial activity. For example, Dion et al. (1988) studied 67 bipolar patients 6 months after hospitalization for mania and found that, although 80% of patients exhibited significant symptom resolution, 51% were either unemployed or working below their premorbid level. However, only ratings of occupation and residence were obtained as assessments of functional recovery. In a separate study in 75 patients with bipolar disorder using the same limited ratings, Tohen et al. (1990a) found that poor occupational status after hospital discharge was associated with the number of previous affective episodes, alcoholism, male gender and psychotic features during the index episode. Strakowski et al. (1998) used the nine-item Premorbid Adjustment Scale (Cannon-Spoor et al., 1982) to assess functional recovery of 83 first-episode bipolar patients following hospitalization for psychotic mania. They only reported results of a summary functional rating, rather than an analysis of individual items. Nonetheless, they found that functional recovery was associated with premorbid employment status and a global rating of premorbid function. Keck et al. (1998), in a similarly designed study of 134 multiple-episode bipolar patients, observed that functional recovery was associated with higher social class. In contrast to these studies of global or limited measures of psychosocial function, Coryell et al. (1993) studied several specific areas of function in 148 bipolar patients using the Longitudinal Interval Follow-up Evaluation (LIFE; Keller et al., 1987) for 5 years of follow-up as part of the Mental Health Collaborative Program on the Psychobiology of Depression. They found that bipolar patients were more likely than healthy subjects to exhibit persistent impairment in occupational and educational achievement, interpersonal relationships, recreational enjoyment, and sexual activity. However, they did not specifically report recovery of these areas of function per se. Gitlin et al. (1995) studied psychosocial outcome in 82 patients followed for 2–6.5 years. They found that symptom level was the best predictor of occupational adjustment, social functioning and family interactions. Although the patients in this study were well-educated, they, nonetheless, exhibited persistent psychosocial impairment longitudinally. However, both of these latter studies included primarily multiple-episode subjects which may obscure associations of some premorbid factors with functional recovery due to the presence of illness chronicity. Prospectively studying first-episode patients may be more likely to identify premorbid factors that predict the course of illness (Tohen et al., 1990b and Strakowski et al., 1998). With these considerations in mind, we examined recovery of the four major areas of function identified in the LIFE (role performance, interpersonal relationships, recreational enjoyment, and sexual activity) during the 8 months following a first psychiatric hospitalization in 50 manic bipolar patients. Specifically, we studied whether these areas of function were independent by examining intercorrelations among the four components, by comparing differences in the courses of recovery, and by evaluating associations with clinical and demographic predictors.

In this patient sample, the four areas of recovery examined — i.e., role performance, interpersonal relationships, recreational enjoyment, and sexual activity — appeared to be relatively independent as they exhibited no significant intercorrelations at baseline or during follow-up, exhibited different courses following hospital discharge, and were associated with different predictors of outcome. Also, with the exception of interpersonal relationships, recovery of no other area of function was significantly associated with symptomatic recovery. These results suggest that outcome in bipolar patients is multifaceted so that attention to different areas of psychosocial function, in addition to symptoms, is relevant for understanding the recovery process. During the 8-month follow-up period, nearly all of the patients exhibited persistent impairment in at least one area of function and less than half achieved good functional outcome, which we defined as recovery in three of the four areas of function. These results are consistent with a number of other studies (Dion et al., 1988, Tohen et al., 1990a, Tohen et al., 1990b, Coryell et al., 1993, Gitlin et al., 1995, Goldberg et al., 1995, Keck et al., 1998, Strakowski et al., 1998 and Gitlin and Hammen, 1999) and suggest that psychosocial impairment occurs in most bipolar patients following acute affective episodes. This may be particularly problematic in first-episode patients such as these, as persistent psychosocial impairment during short-term follow-up may be a harbinger of chronic or treatment-resistant affective illness in the long-term. As our study continues to progress, we hope to specifically identify predictors of developing illness chronicity. Gitlin et al. (1995) found strong associations between levels of symptoms (expressed on a three-point scale) and several aspects of psychosocial outcome. This approach differed from the present study as it did not specifically examine associations between symptomatic and functional recovery, but rather examined associations in overall functions and symptoms over time. Nonetheless, similar to Gitlin et al. (1995) we found a significant association between recovery of interpersonal function and symptomatic recovery. However, in other areas of recovery of function, significant associations with symptomatic recovery were not observed, similar to previous reports ( Coryell et al., 1993, Keck et al., 1998 and Strakowski et al., 1998). These contrasting results suggest that future analyses should examine symptomatic recovery and both syndromal and sub-syndromal affective symptom effects on aspects of psychosocial outcome. In this study, functional recovery was also not associated with the number of nonpharmacologic mental health contacts. Most of these latter contacts in this sample were limited to case management, rather than specific psychotherapies, as noted. These findings suggest that strategies in addition to standard pharmacotherapy and case management are necessary to address the psychosocial impairment of bipolar disorder to potentially prevent the development of illness chronicity. Unfortunately, such strategies are not yet well established. The predictors of recovery in the different areas of function identified in this study suggest some areas for developing treatment strategies in future studies. For example, premorbid socioeconomic (educational and employment) status was strongly associated with both recovery of role performance and overall good outcome. This association has been commonly reported in other studies as well (Tohen et al., 1990a, Tohen et al., 1990b, Gitlin et al., 1995, Keck et al., 1998 and Strakowski et al., 1998). These results imply that integrative treatments to help patients advance their education and job skills may lead to significant overall functional improvement. Similarly, the association of recovery of interpersonal relationships with symptomatic recovery highlights the importance of symptom control for patients to restore relationships with family and friends after acute affective episodes. In this sample, this problem appears to be more difficult in patients who experienced shorter index affective episodes. This finding is counter-intuitive and the reasons for it are not clear. Perhaps patients with longer index affective episodes experienced a more gradual illness onset so that they developed ways to compensate for affective symptoms in interpersonal relationships that patients with shorter index episodes and more acute illness onsets did not. Alternatively the statistical model may not adequately control for the lower baseline level of interpersonal relationships that patients with longer index episode durations demonstrated as compared to those with shorter index episodes. Clearly, the interaction between episode onset and recovery of function requires additional study. Several limitations must be considered when interpreting these results. First, this is a single-site study of hospitalized patients, thereby potentially limiting generalizeability of the findings. Nonetheless, many of the findings are consistent with reports from a number of diverse research settings and study designs. Second, many of the rating scales were not designed specifically for repeated assessments in outcome studies. However, these measures have high face validity in this patient population and the primary ratings instrument (the LIFE) is a well-established outcome measure (Keller et al., 1987 and Coryell et al., 1993). Medication levels were not routinely obtained as part of this study, so ratings of compliance depended primarily on the patient’s report, augmented by reports from family members and clinicians. Previous studies have used similar measures and this approach to the assessment of compliance is consistently associated with symptomatic outcome (Keck et al., 1998 and Strakowski et al., 1998). Third, with larger numbers of subjects, other variables, that contributed smaller effects to the overall logistic regression models might be identified as significantly associated with outcome. However, as indicated in the statistical analysis section of this paper, the number of subjects included provided power to detect medium to large effect sizes, suggesting the most clinically relevant variables contributing to outcome were probably identified. Fourth, the follow-up period is relatively short, and different associations and predictors may be identified over a longer interval. Finally, even though this study extends previous work by investigating a number of areas of function in a first-episode sample, these functional areas could be examined in greater detail and other areas of function that were not studied may also be relevant to outcome. Indeed, we are hopeful this report will generate this type of research. Despite its limitations, this study suggests that functional recovery following a first manic episode is multi-dimensional and that these different dimensions may require different treatment strategies to achieve maximal improvement. Future studies that identify strategies to compensate for premorbid predictors of poor outcome may lead to treatments that prevent the development of chronic bipolar illness.