Copyright ª Blackwell Munksgaard 2005

Bipolar Disorders 2005: 7: 159–165 BIPOLAR DISORDERS

Original Article

Quality of life for patients with bipolar

disorder: relationship with clinical and
demographic variables
Sierra P, Livianos L, Rojo L. Quality of life for patients with bipolar Pilar Sierra, Lorenzo Livianos and
disorder: relationship with clinical and demographic variables. Luis Rojo
Bipolar Disord 2005: 7: 159–165. ª Blackwell Munksgaard, 2005
Psychiatric Unit, La Fe University Hospital,
Valencia, Spain
Objectives: The aim of this study was to assess the quality of life in
bipolar disorder patients, and to analyze a set of clinical variables and
sociodemographic data that could act as quality-of-life predictors.

Methods: The study sample included 50 euthymic outpatients

attending a specific bipolar patient unit. Patients were assessed with the
Clinician-Administered Rating Scale for Mania, and the Hamilton Scale
for Depression. To evaluate quality of life, all patients received the
Spanish version of the SF-36 Health Survey. At the same time,
sociodemographic and clinical data were obtained. The scores were
compared with those of a control group representative of the general
population.

Results: The group of bipolar patients obtained statistically

significantly lower scores on all the subscales when compared with the
Key words: bipolar disorder – measurement –
control population. No statistically significant differences appeared when
quality of life – SF-36
comparing the SF-36 scores with the demographic variables.
Received 31 December 2003, revised and
Conclusions: Bipolar patients experience lower functioning and well-
accepted for publication 29 December 2004
being even in the stable phase of the disorder. Due to the great impact of
bipolar disorder on many areas, it would be of interest to know the Corresponding author: Pilar Sierra SanMiguel,
clinical predictors related to patient quality of life, as this would Avda Campanar no. 21, 46009 Valencia, Spain.
contribute to the design of different clinical interventions. Fax: 34 961973254; e-mail: sierra_pil@gva.es

The basic conceptions, fundamentally based on
Kraepelin’s work, held that schizophrenia and
manic-depressive disorder differed in that the
former was inevitably associated with cognitive
impairment and its repercussions on the patient’s
psychosocial circumstances and quality of life,
while this did not occur in the latter (1). Current
theories are not as optimistic regarding the prog-
nosis for bipolar disorder. Over time, studies have
confirmed that up to a third of patients show a
social and intellectual impairment that persists in
The authors of this paper do not have any commercial associations
that might pose a conflict of interest in connection with this manu-
script.
the supposedly asymptomatic periods, negatively
affecting their functioning and lowering their level
of well-being (2–6). The cyclical nature of bipolar
disorder, with its many remissions and symptom
rich periods of exacerbation, can affect an indi-
vidual’s physical, emotional, social and functional
well-being and significantly impact their overall
quality of life. However, the conceptual model
based on studies about subclinical symptoms
suggests that the majority of bipolar patients suffer
symptoms most of the time (7), which would
considerably affect their quality of life.
While there have been numerous studies assess-
ing the impact of major depressive disorder on the
quality of life, few have shown attention to bipolar
disorder. A recent review of studies on bipolar
159
Sierra et al.
patientsÕ quality of life (8) came up with four
groups: studies comparing bipolar patient quality
of life with that of patients suffering from other
mental disorders such as unipolar depression or
schizophrenia (9); studies comparing different sub-
groups of bipolar patients among themselves (10–
12); studies evaluating the different characteristics
of the instruments used for measuring quality of
life (13–16); and studies comparing the quality of
life of different bipolar patient subgroups and
evaluating instrument characteristics (17, 18). All
these studies used limited samples; only one study
had a sample of over 100 patients and used a 2-year
longitudinal design (15).
Quality of life is a multidimensional concept,
encompassing different aspects such as physical,
emotional, social, functional and spiritual well-
being (19). With this in mind, this study aimed at
analyzing a series of clinical variables that could
act as quality-of-life predictors in bipolar disorder,
using the SF-36 questionnaire (20). To date, there
is no specific quality-of-life scale for bipolar
disorder. Although several psychometric instru-
ments have been used, the SF-36 is the most widely
used scale for assessing the major health concepts
included in the Medical Outcomes Study (MOS).
Materials and methods
The sample consisted of 50 outpatients from a
hospital unit specifically for bipolar patients in the
city of Valencia. All had been diagnosed with
bipolar disorder (type I, n ¼ 45; type II, n ¼ 5)
using DSM-IV criteria (21). We excluded subjects
who suffered a comorbid mental pathology, sub-
stance abuse (at least during the previous
3 months), or a serious concomitant medical
illness. These subjects were regular patients of
one of the authors (PSSM), who knew them well.
To be included, they had to be euthymic from a
clinical global impression for at least 1 month. This
euthymia, furthermore, had to be confirmed psy-
chometrically, by a score <10 on the Hamilton
Depression Scale (22) and a score <10 on the
Clinician-Administered Rating Scale for Mania
(CARS-M) (23). We used an exclusively clinical
operative definition of euthymia which excluded
the various personal-functioning aspects, so as to
avoid contamination with the quality-of-life ques-
tionnaire. Sampling was sequential, with an initial
group of 100 subjects that was reduced to the final
50 patients who met the previously mentioned
criteria. Quality of life was assessed by having all
patients fill out the Spanish version of the SF-36 as
adapted by Alonso et al. (24). This questionnaire is
designed for self-administration and covers eight of
160
the most important health concepts included in the
MOS: physical functioning, role limitations due to
physical health, bodily pain, general health, vital-
ity, social functioning, role limitations due to
emotional problems, and mental health. It has
been widely used in patients suffering from chronic
physical illness and mental disorders, and has high
validity and reliability (16, 20).
Sociodemographic data (age, sex, marital status,
employment situation) and clinical data (age at
onset, duration of illness, characteristics of first
episode: depressive or manic, lifetime number of
depressive and manic episodes, time elapsed since
last episode, scores on the CARS-M and Hamilton
depression scales, total number of admissions,
admissions for depression and for mania, and
history of suicide attempts over the course of the
illness) were obtained simultaneously.
To compare the results obtained in each SF-36
subscale with the population averages previously
established, we used the mean values obtained by
Ayuso-Mateos et al. (25), who determined the
validity of the Spanish version in the general
population using a representative stratified random
sample of 1250 subjects (623 males and 627
females) aged 18–64 years drawn from a city’s
voting registry.
Statistical analysis was carried out with a com-
mercial software package (SPSS, version 11.5).
Continuous variables were compared with the one-
sample t-test and independent-sample t-test, while
dichotomous variables were analyzed with Fisher’s
test. Within the bivariate statistics, we used the chi-
square test for qualitative variables, one-way
analysis of variance for quantitative–qualitative
variables, and the Pearson correlation coefficient
for cases of two quantitative variables. Given the
high number of analyses carried out, we set the
p-value at 0.001.
Results
The final sample consisted of 50 patients, 20 men
and 30 women (average age: 45.14 ± 12.9).
Tables 1 and 2 show the sociodemographic data
and clinical variables. The patients scored very low
on the two CARS-M subscales (CARS-M mania
0.9 ± 0.88; CARS-M psychoticism 0.7 ± 0.81),
and higher on the 17 items of the Hamilton
Depression Scale (3.10 ± 1.79). Table 3 shows
the correlations between the SF-36 subscales, the
HDRS and the CARS-M. Some factors, such as
general health, social functioning, role limitations
due to emotional problems and mental health, are
strongly correlated with the Hamilton Depression
Scale. This might be interpreted as the effect of a
 Quality of life in bipolar patients

Table 1. Sociodemographic variables of the sample clinical point of view and also from a psychometric
Variables, n (%)
perspective. In fact, the patientsÕ low scores on the
Hamilton Depression Scale (3.1 ± 1.8) confirm
Sex this.
Male 30 (60) The one-sample t-test scores of bipolar patients
Female 20 (40)
on all of the SF-36 subscales were significantly
Marital status lower than those of controls (Table 4). Figure 1
Single 13 (26) shows these results and Fig. 2 shows error bars.
Married 30 (60)
Separated/divorced 4 (8)
No statistically significant differences appeared
Widow/er 3 (6) when comparing the SF-36 scores with the demo-
graphic variables analyzed, such as marital status,
Employment situation
Active 11 (22)
employment situation or sex (Table 5), or with the
Temporarily disabled 6 (12) clinical variables, such as age at onset, duration of
Permanently disabled 12 (24) illness, or number of admissions (Table 6). One
Unemployed 2 (4) scale however – role limitations due to emotional
Housewife 12 (24) problems – did yield significant scores (p < 0.001)
Student 1 (2)
Retired 6 (12)
as a function of the increase in depressive episodes.
The remaining correlations did not reach the pre-
set level of statistical significance. We also failed to
Table 2. Clinical variables of the sample
find differences when using a t-test to compare the
Variables Average ± SD type of bipolar disorder (I or II) with the scores on
the different SF-36 subscales, or when taking into
Age at onset (years) 29.44 ± 11.07
account the presence or absence of previous
Time elapsed since last episode (months) 23.06 ± 31.12
Characteristics of first episode, n (%) admissions.
Manic 37 (74)
Depressive 13 (26)
Number of episodes 7.94 ± 4.06 Discussion
Manic episodes 2.92 ± 2.26
Our study coincides with earlier studies suggesting
Depressive episodes 3.66 ± 2.25
Hypomanic episodes 1.36 ± 1.86 that bipolar patients experience lower functioning
CARS-M and well-being even in the stable phase of the
Mania 0.9 ± 0.88 disorder (2, 3, 10, 17, 18, 26). Due caution is
Psychoticism 0.7 ± 0.81 necessary, however, because our study was limited
Hamilton depression 3.1 ± 1.79
by sample size. In addition, some of the data, such
Number of admissions 1.8 ± 2.1
Admissions for mania 1.52 ± 1.99 as the number of episodes or the age at onset, were
Admissions for depression 0.28 ± 0.7 gathered retrospectively and may, thus, be distort-
Suicide attempts 1.71 ± 0.44 ed by recall.
Our patients scored significantly lower on all the
Table 3. Correlations of the SF-36 scales with the HDRS and CARS-M SF-36 subscales when compared with the general
subscales (n ¼ 50) population, in spite of the fact that we used strict
Hamilton CARS- CARS-
SF-36 subscale Depression mania psychoticism Table 4. Mean, standard deviation and one-sample t-test on the SF-36
subscales of the bipolar sample and general population*
Physical functioning )0.195 )0.050 )0.042
Role limitations due )0.372 0.029 0.154 Bipolar General
to physical health disorder population*
Bodily pain )0.001 0.181 )0.200 SF-36 subscale (n ¼ 50) (n ¼ 1250) p
General health )0.604* )0.066 0.117
Vitality )0.324 0.281 0.089 Physical functioning 87.7 ± 12.04 94.42 ± 12.82 0.0001
Social functioning )0.616* )0.023 0.181 Role limitations due 70.00 ± 34.25 91.13 ± 25.76 0.0001
Role limitations due )0.488* 0.088 0.217 to physical health
to emotional problems Bodily pain 70.72 ± 23.13 82.35 ± 24.82 0.001
Mental health )0.493* 0.165 )0.007 General health 52.42 ± 19.47 80.00 ± 18.89 0.0001
Vitality 47.00 ± 21.82 69.99 ± 18.45 0.0001
*Significant at 0.001 (two-tailed) Social functioning 72.25 ± 30.01 96.03 ± 14.12 0.0001
Role limitations due 65.33 ± 41.83 90.19 ± 26.03 0.0001
to emotional problems
residual depression, but it should be borne in mind Mental health 65.54 ± 23.41 77.72 ± 17.32 0.001
that the exclusion criteria included the presence of
clear symptoms of depression, both from a global *Reprinted with permission from Ayuso-Mateos J et al. (25)

161
Sierra et al.

100 Bipolar disorder General population

90

80

70

60

50

40

30

20

10

0
Physical RL due to Bodily pain General Vitality Social RL due to Mental
functioning physical health functioning emotional health
health problems

Fig. 1. Mean values on the SF-36 subscales of the bipolar sample and general population.

Physical
110 functioning
RL due to
physical
health
100
Bodily pain

General health

90 Vitality
Social
functioning
RL due to
80 emotional
95% IC

problems
Mental health
70

60

50

40

Bipolar disorder General population

Fig. 2. Error bars on the SF-36 subscales of the bipolar sample and general population.

sample-selection criteria excluding patients with
residual symptoms, psychiatric comorbidity, sub-
stance abuse or concomitant physical illness. As a
depressive mood could distort patientsÕ perceptions
and cause them to overestimate their levels of
functional impairment (27, 28), we selected patients
162
who were affectively euthymic at the time of the
study. As for gender differences, the literature
indicates that bipolar disorder is more disruptive in
women (29). Earlier studies found women scoring
lower on the quality-of-life subscales (10). Our
study, however, found no differences for the
 Quality of life in bipolar patients

Table 5. One-way ANOVA between marital status, employment situation and sex, and SF-36 subscale score (gl ¼ 47)

Marital status Employment situation Sex

F Sig. F Sig. F Sig.

Physical functioning 0.786 0.508 0.453 0.839 0.641 0.428

Role limitations due to physical health 0.217 0.884 1.139 0.357 0.657 0.422
Bodily pain 0.358 0.783 0.931 0.451 1.022 0.317
General health 1.616 0.199 2.077 0.077 0.356 0.554
Vitality 0.785 0.509 0.499 0.805 0.082 0.776
Social functioning 0.635 0.596 0.907 0.500 0.620 0.435
Role limitations due to emotional problems 0.428 0.734 1.094 0.382 3.957 0.053
Mental health 0.196 0.899 0.860 0.532 0.223 0.639

Table 6. Correlation between age at onset, duration of illness, time since last episode, number of episodes, number of depressive and manic episodes, number
of admissions, and number of admissions for mania and depression, and the scores on the eight SF-36 subscales (Pearson correlation)

No. No. No.

Age at Duration Time since No. depressive No. manic No. admissions admissions
onset of illness last episode episodes episodes episodes admissions for mania for depression

Physical functioning )0.205 )0.208 0.210 )0.224 )0.432 0.215 0.122 0.230 )0.116
Role limitations due 0.093 )0.179 0.264 )0.147 )0.350 0.126 )0.075 )0.009 )0.071
to physical health
Bodily pain 0.104 )0.260 0.273 )0.142 )0.281 0.157 0.111 0.220 )0.145
General health 0.150 )0.044 0.288 )0.072 )0.101 0.035 )0.144 )0.151 0.048
Vitality 0.052 )0.122 0.222 )0.030 )0.102 0.108 0.028 0.061 )0.107
Social functioning 0.136 )0.126 0.385 )0.062 )0.255 0.283 0.079 0.151 )0.062
Role limitations due 0.148 )0.147 0.348 )0.245 )0.460* 0.131 )0.060 0.015 )0.013
to emotional problems
Mental health 0.132 )0.120 0.376 )0.071 )0.156 0.221 0.037 0.045 )0.040

*p < 0.001

demographic variables analyzed – marital status,
sex, or employment situation – with respect to
quality of life. Previous studies evaluated the
consequences of mental disorders by analyzing
the percentage of workdays lost. Kessler and
Frank (30) performed a study on the repercussions
of mental illness and found that ÔpureÕ affective
disorders are associated with an increase in average
lost workdays and sick leave when compared with
other ÔpureÕ psychiatric disorders. Although our
sample size was small, we do want to point out the
differences between the bipolar patients and the
general population. According to the National
Statistical Institute’s data (31), employment in
Spain during the third of 2003 (the approximate
period when the present study was carried out)
stood at 54% among the population above
16 years, while unemployment was at 11.73%.
During the last 3 months of 2002, the percentage of
people temporarily unable to work was 1.38%. As
Table 1 shows, 22% of our sample was actively
employed, and 12% temporarily unable to work.
These numbers clearly show the important reper-
cussions of bipolar disorder on patientsÕ employ-
ment situation and its unquestionable impact on
the quality of life.
Interestingly, a referee pointed out the striking
difference in subscale 2 (role limitations due to
physical health). Whether these patients really
had more physical problems than the general
population, or whether this sample, selected for
having no physical ailments, scored differently as
the result of a response bias remains to be
determined.
When considering patient history of the dis-
order, previous studies offer variable results. Some
of them found no predictive factors related to
quality of life (32), while others found that the
longer bipolar disorder lasts, the lower patient
quality of life is (33) and the higher psychosocial
dysfunction (34). Romans and McPherson (35)
found higher rates of marriage breakup and family
conflict in bipolar patients, rates directly related to
the duration of the disorder (34). Previous studies
reported that older bipolar patients with many past
episodes had lower social adjustment (36). In our
study, neither age at onset nor the duration of the
disorder affected the scores on the different sub-
scales. A recently conducted study (13) found that
quality-of-life measures, more than being mere
symptomatic quantifications, could actually pre-
dict the recurrence of depression. Other studies
163
Sierra et al.
confirm that depressive symptoms play a key role
in the quality of life of bipolar patients (33, 37),
which is consistent with our findings. The type of
first episode or the total number of episodes were
not predictive factors, although patients with more
depressive episodes experienced more role limita-
tions due to emotional problems. While the results
were not significant, there was a tendency toward
negative correlations between several subscales and
the number of depressive episodes. Thus, as the
number of such episodes increased, patients would
show a clinical evolution characterized by more
physical and role limitations due to emotional
problems, i.e., a higher degree of interference by
emotional problems in their work or daily activi-
ties, as well as in their physical roles and bodily
pain. Previous studies (35) found that patients with
predominantly manic episodes are not as well
adapted socially than depressive patients, which is
not consistent with our findings. Our study, then,
suggests that quality of life is not influenced by the
total number of admissions or by manic or
depressive episodes.
The present study reiterates the need to more
seriously consider the impairment associated with
bipolar disorder and its repercussions on patientsÕ
quality of life, because lowered well-being causes
future vulnerability. As bipolar disorder greatly
impacts many areas, it would be interesting to
know the clinical predictors that are related to
patient quality of life, as this would allow resources
to be tailored to needs, as well as different clinical
interventions, such as psychoeducational projects,
to be specifically designed to address those aspects.
To achieve this goal, more resources need to be
directed toward the rehabilitation and psychoedu-
cation of these patients. Moreover, pharmacologi-
cal treatment to prevent this impairment may play
a key role in this field in the future.
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