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.
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.