Elsevier

Psychiatry Research

Volume 246, 30 December 2016, Pages 796-802
Psychiatry Research

Is history of suicidal behavior related to social support and quality of life in outpatients with bipolar I disorder?

https://doi.org/10.1016/j.psychres.2016.10.045Get rights and content

Abstract

Bipolar disorder (BD) affects the social functioning and quality of life (QoL) of its patients. This study aimed to investigate whether there is an association between social support (SS), and suicidal behavior in BD I patients compared to healthy controls; secondarily, we evaluated the influence of QoL on those variables. A total of 119 euthymic outpatients with BD I, 46 of whom had attempted suicide (SAs) and 73 who had not (non-SAs), were compared to 63 healthy controls, through the Medical Outcomes Study Social Support Scale and World Health Organization's Quality of Life Instrument. No differences were noted in SS and QoL between SAs and non-SAs. Compared to healthy controls, non-SAs showed lower values in the positive social interaction domain of SS, and the patients, as a whole, showed lower values in affectionate and positive social interaction domains of SS. Compared to healthy controls, SAs had lower values in the environmental domain of QoL, and the patients, as a whole, had lower values in the environmental, social, and psychological domains of QoL. There was positive correlation between SS and QoL. Although BD is a disabling disease, patients receive inadequate SS. Interventions that may alter the SS in these patients should be investigated.

Introduction

Bipolar disorder (BD) is a chronic, recurring illness, with estimated prevalence rates of 2% if only the classic presentation of symptoms is considered. When subsyndromic forms of BD are included, prevalence rates reach 4% in the general population (Merikangas et al., 2011). There are negative impacts on the overall functioning of the patient, placing BD among the top 10 causes of years lost to disability (Murray and Lopes, 1997). Furthermore, the literature shows that BD is a potentially lethal illness. It is estimated that 25–50% of patients with BD will attempt suicide at least once in their lifetime, and that 15–19% will commit suicide (Novick et al., 2010; Pompili et al., 2013). Given these statistics, studies that investigate not only the risk factors for suicide, but also the protective factors against suicidal behavior in this population, are relevant (Kleinman and Liu, 2013). In fact, little attention has been given to protective factors; thus, as psychosocial factors may reduce the risk of suicide, we observed the need for better understanding the influence of these aspects (Finseth et al., 2012, Schaffer et al., 2014).

Among the constructs that measure psychosocial aspects, two different, albeit related, concepts are noted: 1- structural social support (SS) and 2- functional SS. The structural SS comprises the quantitative aspects of social relationships and includes the number of people with whom the individual maintains contact or a social bond (social network) and who might or might not offer help. This type of support also involves the interconnectedness of a person's relationships and describes the existence of and relationships among network members. The functional SS comprises the qualitative dimension of the relationship, referring to the resources made available to people in time of need, such as emotional, material, and affective assistance. Furthermore, SS refers to the individual's perception of being valuable to the groups of which the individual is a part (Sherbourne and Stewart, 1991, Helgeson, 2003, Griep et al., 2004).

Among the constructs that measure psychosocial aspects, two different, albeit related, concepts are noted: 1- structural social support (SS) and 2- functional SS. The structural SS comprises the quantitative aspects of social relationships and includes the number of people with whom the individual maintains contact or a social bond (social network) and who might or might not offer help. This type of support also involves the interconnectedness of a person's relationships and describes the existence of and relationships among network members. The functional SS comprises the qualitative dimension of the relationship, referring to the resources made available to people in time of need, such as emotional, material, and affective assistance. Furthermore, SS refers to the individual's perception of being valuable to the groups of which the individual is a part (Sherbourne and Stewart, 1991; Helgeson, 2003; Griep et al., 2004). Previous studies regarding SS and BD reported that patients with BD receive less SS, and that those with deficient SS have poorer symptomatic outcomes than healthy controls (Romans and MacPherson, 1992; Beyer et al., 2003; Wilkins, 2004; Eidelman et al., 2012). In addition, prospective studies confirmed that SS has a positive influence on only the recurrence of depressive episodes (Johnson et al., 2000, Cohen et al., 2004, Weinstock and Miller, 2010, Oddone et al., 2011); another study showed the positive effect of SS only in the manic period (Strauss and Johnson, 2006). Others affirm that the presence of SS is important in reaching remission for both states of the illness (O’Connell et al., 1985, Kulhara et al., 1999, Johnson et al., 2003). Additionally, only one study showed that SS is not an important factor in the individual's recovery (Staner et al., 1997).

Although there are favorable empirical results corroborating the position that satisfactory SS provides beneficial consequences, data concerning this topic are still scarce and methodologies vary, such as including patients in different phases of the disease and simultaneously evaluating patients with different subtypes of BD (types I and II). Moreover, most studies have small sample sizes.

The influence of SS in the life of the BD patient is misunderstood. According to the World Health Organization, quality of life (QoL) is described as an “individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, stands, and concerns” (The WHOQOL group, 1995). Despite the use of adequate pharmacotherapy, the course of BD is often characterized by persistent symptoms and by high rates of relapse, recurrence, and hospitalizations. After the acute phase, although the individual may recover substantially, reaching a state of symptomatic remission, the patient still presents an elevated degree of psychological suffering, cognitive dysfunction, and losses in the social and work spheres, with a subsequently negative impact on QoL. The subsyndromal symptoms, especially depressive ones, may remain, thus resulting in a higher frequency of recurrences, with the exacerbation of symptomatology and a decrease in one's general health (Dean et al., 2004, Çakir and Ozerdem, 2010). Within this context, routine inclusion of QoL assessment in clinical practice is helpful, as QoL may be considered an important indicator of the level of efficiency of medical treatment (Murray and Michalak, 2012).

Thus, to our knowledge, this is the first study that aimed primarily to examine whether there is an association between SS and suicidal behavior in BD I patients, evaluated only in the euthymic phase, according to strict symptomatologic criteria. In addition, our second aim was to assess the relationship between SS and QoL. Our main hypothesis is: SAs have lower values in the domains of SS and QoL compared to non-SAs and health controls.

Section snippets

Participants

This cross-sectional study evaluated a convenience sample represented by BD I patients and healthy controls. Participants were recruited from an outpatient clinic, which also has a research center, the Mood and Anxiety Program, located at a teaching hospital at Federal University of Bahia-Brazil.

Sample

The SA group had more women (n=31; 67.4%), a higher presence of axis II comorbidity (p=0.041), and lower values of year of study (p=0.023). SAs and non-SAs showed higher presence axis II comorbidity (p=0.001) and lower rates of employment (p<0.001) and individual income (p=0.019) than healthy controls (Table 1). In the group of bipolar men, the percentage who attempted suicide was 55.5% (15/27), and in the group of bipolar women, the percentage who attempted suicide was 33.7% (31/92) (p=0.04).

SS and QoL

Discussion

To the best of our knowledge, the present study is a pioneer research study on examining the association between SS, QoL, and suicidal behavior in patients with BD I, evaluated only in the euthymic state and according to rigid criteria of euthymia. The use of such restrictive inclusion criteria is intended to reduce biases in the answers; in other words, the intent was to prevent distortion in the understanding of the patients’ reality in relation to their own vision of SS and QoL. Although, we

Disclosures

The authors of this paper do not have any commercial associations that might pose a conflict of interest in connection with this manuscript.

Role of the funding source

This project has been supported by the Mood and Anxiety Disorders Program (CETHA), Salvador-Bahia, Brazil. The CETHA had no further role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication. This study was funded by Coordination for the Improvement of Higher Education Personnel (CAPES).

Acknowledgments

The authors would like to thank all of the patients who consented to be included in this study for their cooperation and resilience in completing the assessments.

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