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Evidence-Based Reviews

Help your bipolar disorder patients remain employed

Integrate work-related issues as you address symptoms, medication, and function

Vol. 8, No. 9 / September 2009
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Mrs. S, age 34, worked as an office manager with responsibilities for more than 40 employees for 5 years. Starting in her mid 20s she had repeated periods of depression, binge drinking, and risk-taking that were treated ineffectively with antidepressants. Ultimately, she was fired from her job.

Eventually Mrs. S was diagnosed as bipolar and over time responded well to a mood-stabilizing regimen. She now desires to return to work, both for financial reasons and for the sense of accomplishment that comes from working. Initially, personnel managers review her résumé and tell her she would be bored by the routine nature of entry-level positions, or they offer her jobs with major responsibilities. She accepts a high-level position but soon leaves, feeling overwhelmed by the stress.

Bipolar disorder’s long-term course presents a therapeutic challenge when patients desire to remain employed, seek temporary or permanent disability status, or—most commonly—attempt to return to employment after a period of inability to work. As the experience of Mrs. S illustrates, previous capabilities that appear higher than the person’s present or recent work experience are a key issue to address in interpersonal therapy.

Evidence-based research is informative, but ultimately you must apply judgment and flexibility in setting and revising goals with the bipolar individual. Attention to the disorder’s core characteristics can help you equip patients for work that contributes to their pursuit of health.

Obstacles to employment

Role function. Bipolar disorder impairs family and social function in approximately one-half of persons with this diagnosis, a higher impairment rate than in persons with major depression.1

Cognitive function. Bipolar disorder patients have subtle sustained impairments in cognitive function, particularly working memory.2,3 These deficits—although generally much less severe than in persons with schizophrenia—contribute to workplace and educational difficulties.

Unstable mood. Some symptoms associated with elevated mood contribute to functional impairment. These are not limited to mania or hypomania but also can be prominent in mixed states and depression.

A study from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) found that two-thirds of 1,380 depressed bipolar I and II patients had ?1 concomitant symptoms principally associated with manic states. The most prominent were distractibility, pressured speech and thoughts, risky behavior, and agitation.4 Each of these—or, more often, all of these—can interfere with work responsibilities.

Circadian rhythm pattern. Sleep disturbances in bipolar disorder differ from those associated with other medical conditions. Bipolar patients’ tendency to increase their activity and interests in the evening may keep them awake into the early morning hours. Insufficient sleep and impaired daytime cognition and alertness related to idio syncratic circadian rhythms can interfere with job requirements.5 The structure of employment can help many bipolar patients maintain effective sleep patterns as well as waking activities (Box 1).

Some individuals recognize their disturbed activity pattern, but many view it simply as the way they approach a day. For the latter group, a sustained treatment effort is needed to help them recognize the adverse consequences of the pattern and develop a more effective daily routine.

Adverse treatment effects. Although important, this core medical issue is not central to the interpersonal focus of this article. The simple tolerability objective in prescribing medications—and less frequently therapies such as electroconvulsive treatment—is to avoid dosages that impair concentration, alertness, or motor speed and accuracy. Similarly, avoid medications that can cause physical changes noticeable to others—such as tremor, sleepiness, or significant weight gain—or adjust dosages to eliminate these side effects.

Box 1

Therapeutic benefits of work for bipolar disorder patients

Work, defined as what we do to make a living, is useful for most individuals. For persons with bipolar disorder, work has additional benefits. Having a job aids in structuring their daily activities, which tend to be skewed by circadian rhythm-linked problems of inadequate sleep or sleep that starts too late and extends into the day. The routine expectations of a work schedule also can counteract the distractibility and unproductive multitasking common in some bipolar disorder patients.

These benefits are not guaranteed and vary considerably across occupational settings, but patients and family members readily understand this aspect of work. Its benefits can serve as an important impetus for patients to persist in efforts to attain employment, even in the face of obstacles.

Bipolar symptom domains

Anxiety is recognized as a separate and major domain in bipolar psychopathology,6 contributing strongly to poor outcomes. Although anxiety is somewhat more predominant in depression and mixed states, it is common in manic and recovered bipolar states as well.

Social anxiety and panic states appear to be most specifically associated with bipolar disorder.7 Because these types of anxiety entail excessive fearful responses, psychotherapeutic techniques including extinction approaches can be helpful.

Depression in bipolar disorder tends to manifest as slowed motor and cognitive function, which is likely to be evident in work situations. Additionally, loss of social interests—one of the most common and severe aspects of depression in bipolar disorders—is likely to be evident to coworkers and to negatively impact work effectiveness.

Irritability occurs most frequently in mixed bipolar states but also is characteristic of—though generally less intense in—depressed and manic clinical states. Even when strictly internal and subjective, irritability can reduce an individual’s confidence and work effectiveness. Expressed irritability, from minor annoyances to explosive outbursts, can have serious employment consequences, including termination.

Manic symptoms. The impulsivity that is common in bipolar mania can interfere with work. Acting without considering consequences, taking undue risks, or reaching conclusions on inadequate information can cause problems, including physical harm to self or coworkers. Excessive talking—usually associated with internally recognized racing thoughts—can be a nuisance when mild or problematic if it interferes with customer or coworker interactions.

Hyperactivity and increased energy may be perceived as behaviors that facilitate productivity at work (Box 2).8-10 The adaptive characteristics of many hypomanic states are infrequent or absent in depressive, manic, and mixed manic clinical states, however.

Psychosis is principally associated with manic episodes, but it can be a component of any symptomatic clinical state. Delusional ideas or persecutory thoughts are rarely compatible with a work environment, in part because of potential risks to others.

Box 2

Hypomanic energy on the job: Constructive or destructive?

For some purposes, bipolar disease confers social and employment advantages. Common, frequently adaptive behavioral characteristics of hypomania include:

  • perseverance
  • high energy
  • heightened perceptual sensitivity
  • exuberance and playfulness
  • optimism.

Increased energy and mild degrees of hyperactivity—as well as thinking along creative, multisystem lines—can benefit work productivity, customer interactions, and work group relations. Heightened confidence and social interests can be valuable in some sales and marketing activities.

Although these attitudes and behaviors can have constructive effects, patients need to understand their limits and destructive potential. This is not a straightforward issue, as patients may not have self-awareness of some adverse consequences of characteristics such as irritability, risk taking, or inappropriate sexual advances. A phenomenon little described in clinical literature but relatively common in biographical accounts of persons with bipolar disorder is that friends or coworkers may encourage, rationalize, and take advantage of an individual’s hypomanic energy, thwarting effective interventions.

Source: References 8-10

Componential treatment

Bipolar disorder’s multiple symptom domains suggest a componential approach to treatment. It may be useful to convey this concept metaphorically to the patient. When working on a jigsaw puzzle, a section that has been put together can be largely left intact and attention turned to other sections of the puzzle. Similarly, once a particular bipolar component is well managed—whether via medication, lifestyle, attitudes, or combinations of these—that symptom is likely to remain stable, barring a new insult/stressor (such as a medical condition requiring drugs that interfere with the bipolar regimen).

If mood stabilizers control risky behavior, impulsivity, and affective lability, the regimen generally will remain effective. If residual or new problems develop in another area (such as anxiety, sleep cycle, or irritability), choose drug regimens and psychoeducation approaches that are compatible with the mood-stabilizing plan. This attitude toward treatment:

  • is reassuring to most patients, who come to see a new or recurring problem in one domain as not inherently a harbinger of complete relapse
  • can reduce patient- or clinician-initiated deletions and additions of medications in a regimen that has been established as effective.

Autobiographical accounts of persons with bipolar disorders can be useful in educating patients about the considerations presented here. Actress Patty Duke made these observations in describing the gradual development of an effective treatment for her severe bipolar disorder:

I work at not flying off the handle…and I’m much better at it. My general medical bills dropped by $50,000 a year since my bipolar diagnosis and treatment. Until then, I was always in the hospital for some phantom illness. I was there with real symptoms born of depression. I haven’t been in the hospital since I was diagnosed.

My recovery from manic-depression has been an evolution, not a sudden miracle. For someone who spent 50% of her life screaming and yelling about something, I am now down to, say, 5%.11

Psychosocial factors to consider

Stigma in the workplace. Although most coworkers are tolerant of and fair-minded about the functional difficulties common in symptomatic bipolar disorder, some will have biased, inaccurate views about psychiatric conditions. Advise bipolar individuals to make case-by-case decisions about whether to provide personal information to other employees and, if so, how much.

As with most medical conditions, the default choice will be to not discuss personal information in the workplace. Some coworkers, however, might appreciate learning of the bipolar condition (for example, a supervisor who seems empathic to an employee’s seeming stressed state).

Realistic expectations. Most clinicians recognize that relief from a syndromal bipolar state is achieved more quickly than a sustained recovered status in which symptoms are minimal. Attaining functional capacity in a normal range also lags, both in time and in the proportion of persons who ever achieve sustained good function.12 Patients, their families, and often employers may have unrealistic expectations about early resumption of work after a depressive or manic episode resolves.

Ethnic considerations. Some literature suggests ethnic differences in the initial presentation of bipolar disorder, with more severe manifestations in some populations particularly if psychosis is a component symptom.13 Additionally, some cultural views about stigma from illness can add to patients’ or family members’ reluctance to re-enter the workplace.

Socioeconomic status. Sometimes bipolar illness puts out of reach the occupational activities that an individual has previously undertaken or that are characteristic of the family’s experience and expectations. Resistance to a change in self-concept can add to the difficulty in successfully moving a patient to consider employment that is more routinized and less intellectual or decisional in nature (Box 3).14

Divergence in education vs work status. Persons with bipolar disorders often have substantial divergence between high educational attainment and lower work performance. When this is the case, all or most of the factors reviewed in this article probably have contributed. Mrs. S’s experience illustrates this aspect of our care for persons with bipolar disorders.

Box 3

Overcoming patient fixation on the idealized working self

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