Disability in Bipolar Affective Disorder and Obsessive Compulsive Disorder: A Comparative Study

INTRODUCTION

Disability is an umbrella term which covers impairments, limitation in day-to-day activities, and restriction of social and occupational participations. Disability is thus not just a health problem. It is a complex phenomenon that reflects the interaction between features of a person’s body and the society in which he or she lives. The World Health Organization (WHO), the United Nations’ public health arm, came up with its new workout for disability and health in 2001 called the International Classification of Functioning, Disability, and Health, known as the ICF.¹ There has been a long struggle between competing conceptual models to define disability: the medical model versus the social model. This new international definition incorporates the best of both models and offers a new perspective for thinking about disability and minimizing negative effects. This new model is called the biopsychosocial model, which provides the basis for the new approach to understanding disability. According to Census 2011, 2.7% of the total number of disabled persons in India suffered from mental illnesses, among which 2.8% are males and 2.6% are females.² According to the National Mental Health Survey (2015–2016), almost half of the persons suffering from mental illnesses suffered disability in any one of the domains of social life, family life, and work.³ Bipolar Affective Disorder (BPAD) and Obsessive Compulsive Disorder (OCD) are two mental disorders that, due to their distinct symptomatology, cause a lot of disability to the persons affected.

BPAD is the sixth leading cause of disability among all medical disorders worldwide.⁴ Loss of disability-adjusted life years due to BPAD is more than epilepsy, Alzheimer’s disease, and diseases like cancers.⁵ Bipolar disorders have been associated with much more dysfunction than it had been thought earlier, more so in the areas of social adjustment and vocational functioning. Among the areas of social adjustments, there are marital and residential status, interpersonal activities, and leisure activities, all of which are impaired in bipolar disorders.⁶ The factors mostly associated with these impairments are depressive features, psychotic symptoms, poor premorbid functioning, lack of social support, and poor socioeconomic conditions.⁷ A study by Martinez Aran has suggested that, among various factors, cognitive symptoms were most strongly associated with disability in bipolar disorders.⁸ It was further supported by other studies which postulated that among the cognitive factors, attention and immediate verbal memory dysfunction were frequently associated with disability.^9,10 Another study by Goswami found that neurological soft signs were also strongly correlated with disability in the case of bipolar disorder.¹¹

OCD, which was previously considered a rare and neglected illness, has now emerged as one of the five most significant mental disorders and one of the ten medical illnesses associated with the highest disability throughout the world. It is now a proven fact that, like bipolar disorders, OCD is associated with a distinct pattern of functional impairment and disability. A study by Trivedi found that impaired cognitive functioning may result in these functional impairments, and among the cognitive domains, working memory, attention, and executive functioning were most severely affected.¹² Another study by Jakoby reported depressive symptoms determined functional impairment and disability in OCD patients.¹³ A study done by Calvocoressi et al. found that, among 455 subjects of primary OCD, 17% were hospitalized for disability-related problems, including disruption of the home environment, poor self-care, and self-injurious behavior.¹⁴ Therefore, keeping in mind the disabling potential of these two psychiatric disorders, the index study was undertaken in a tertiary care teaching hospital in Eastern India to assess and compare the disability caused by them.

MATERIAL AND METHODS

The present study was a single-center, cross-sectional, single-interview study that was approved by the Institutional Ethics Committee. The study was conducted at the outpatient psychiatry department of Tertiary Care Teaching Hospital in West Bengal between August 2018 and July 2019. Consecutive patients attended the psychiatry outpatient department and were diagnosed as per International classification of disease (ICD) 10 Diagnostic criteria for research (DCR) as either BPAD (both manic and depressive episode) or OCD by two senior consultant psychiatrists of the department with a duration of illness of 2–5 years, aged between 18 and 60 years, and accompanied by at least one reliable informant. Patients willing to take part in the study and giving valid informed consent fulfilling inclusion and exclusion criteria were included in the study. Patients having other psychiatric disorders or mental retardation, or other chronic debilitating mental illnesses were excluded from the study. Convenience sampling was done. The sample size was determined based on practical considerations, including the availability of resources and estimated participant accessibility. A target of 50 participants in each group was set to ensure sufficient preliminary data collection and to facilitate meaningful analysis, and was not based on formal statistical power calculations. Patients in all phases of illness (acutely symptomatic, stable, and in remission) were included, and they were on medications at the time of intake. The total study sample consisted of 100 patients (50 subjects with BPAD and OCD each). The subjects were further assessed for disease severity using the Yale Brown Obsessive Compulsive Scale (Y-BOCS) and the Young Mania Rating Scale (YMRS)/Hamilton Rating Scale for Depression for OCD and BPAD, respectively. Disability was assessed with the Indian Disability Evaluation and Assessment Scale (IDEAS). The two groups were compared on various domains of IDEAS, and the relation between disease severity and certain disease parameters was also explored in each group.

RESULTS

Table 1 shows the socio-demographic characteristics of the two groups. The sample showed a female (54%) and male (58%) preponderance in the bipolar and OCD group, respectively. The majority (54%) in the bipolar group were Muslims, whereas the majority (62%) in the OCD group were Hindus. In both groups, the majority hailed from the nuclear family had a rural background and were educated up to the 12^th standard. The mean Y-BOCS, Hamilton scale for anxiety (HAM-A), and Hamilton scale for depression (Ham-D) scores were 24 ± 2.87, 19 ± 1.39, and 21 ± 3.21, respectively.

Table 2 shows the percentage of subjects suffering from no, mild, moderate, severe, and profound degrees of disability in various domains of IDEAS in both the groups. In the domain of self-care, the majority (42%) of the subjects in the bipolar group were moderately disabled, whereas the majority (50%) of the subjects in the OCD group were mildly disabled. In the domain of interpersonal activities majority (40%) of the subjects of the bipolar group were severely disabled, and in the OCD group, mild disability was the maximum number (56%). In the communication domain, half (50%) of the subjects in the OCD group were free of any disability or had mild disability (46%), whereas the majority (46%) of the subjects were moderately disabled in the bipolar group. In the work domain, two-thirds (60%) of the bipolar patients were severely disabled, and among the OCD patients, nearly half (52%) of the subjects were moderately disabled.

Table 3 shows the total amount of disability (Global Disability) of both groups. The majority (68%) of the subjects with OCD had mild disability, whereas the majority (88%) of the subjects in the bipolar group were moderately disabled. Neither of the groups had any person suffering from profound disability.

Table 4 shows the correlation between disease severity in both disease groups with the individual domain scores of IDEAS and global disability. Correlation between disease severity and disability showed that the YMRS total score and HAM-D total score both had significant positive correlation with all domains of IDEAS and IDEAS total score in the bipolar group, while in the OCD group, obsession, compulsion, and Y-BOCS total score all had positive correlation with IDEAS global score and individual domains of IDEAS except for the communication domain (when obsession and compulsion were separately accounted for).

Table 5 shows the correlation of the duration of illness with the individual scores of the domains of IDEAS of both disease groups. Duration of illness had a significant positive correlation with the IDEAS total score and individual domain score of IDEAS, except for the self-care domain in the bipolar group and the communication domain in the OCD group.

Table 6 shows the comparison of scores in the individual domain of IDEAS and the IDEAS global score in both groups. It was seen that the individual domain score in IDEAS and the IDEAS global score were significantly higher in the bipolar group compared to the OCD group.

DISCUSSION

The aim of the index study was to assess the disability among patients with BPAD and OCD using IDEAS and to compare the domains of IDEAS between the two groups.

In the index study, most of the subjects in the bipolar group were female, and most of the subjects in the OCD group were male, which was in contrast to a study by Chaudhuri et al. that showed male predominance in all the seven disease groups except the OCD group.¹⁶ In this study, authors found that 36% of the bipolar patients were unemployed. This was almost double, as was shown by a study by Carlson et al., which showed 15% of bipolar patients were unemployed.¹⁷ In contrast, another study conducted later by Dion et al. found that 57%–65% of bipolar patients were unemployed.¹⁸ In the index study, 36% of OCD patients remained unemployed, whereas a study by Koran et al. found 22% unemployment in OCD patients.¹⁹ The higher unemployment rate in both the study groups compared to Western studies might be due to the overall high unemployment rate in India and in the state of West Bengal in particular.

In this study, in the bipolar group, 2 (4%) subjects, 44 (88%) subjects, and 4 (8%) were mildly, moderately, and severely disabled, respectively. In contrast, another study by Anupama et al. showed that 25% had mild, 50% had moderate, and 25% had severe disability.²⁰ In their study, Mehta et al. found that all bipolar patients had impairment in work, interpersonal relations, and life satisfaction, and most of them had moderate to severe impairments, which was similar to the index study in which the majority of bipolar subjects had a moderate degree of disability in self-care, interpersonal activity, communication, and the work domain.²¹ In the OCD group majority of the subjects had mild to moderate disability, which was similar to the findings by Mohan et al.²² This finding once again reinforces the fact that both bipolar disorder and OCD contribute to a significant amount of disability.

The index study showed that the YMRS total score and the HAM-D total score both had significant correlations with all domains of IDEAS and with the IDEAS global score. A previous study by Chaudhuri et al. found similar results in bipolar patients.¹⁶ This finding was also similar to another study by Simon GE et al., which found that manic/hypomanic symptoms and depressive symptoms had significant associations with all domains of disability.²³ The index study also found that, among the components of IDEAS, impairment in the work domain had the strongest correlation with disease severity in both the manic and depressed groups. This impairment in work and resulting severe unemployment rate in bipolar patients was reflected in other studies.^10,24 Another similar study by All-Yahya also found that BPAD disease severity had a positive correlation with disability measured by World Health Organisation Disability Assessment Schedule 2 (WHO/DAS2).²⁵ Therefore, across studies, including the index study, the uniform finding was that the severity of depressive and manic symptoms caused significant impairment of work. This underscores the importance of vocational rehabilitation while formulating the management plan for such patients.

In the index study, the highest mean score of disability was in the work domain in both the bipolar and OCD groups, and the lowest mean score of disability was in the self-care and communication domain in the bipolar and OCD group, respectively. A study by Mohan et al. showed the mean score of disability was highest in the communication and understanding domain and lowest in the self-care domain.²²

The index study showed that obsession, compulsion, and total score on Y-BOCS all had a positive correlation with the IDEAS global score, with compulsion having a stronger correlation. Another study by Goodman et al. found that functional impairment was more due to compulsion than obsession score.²⁶ Gururaj et al. found that severe OCD was associated with significant disability.²⁷ Another study by Al-Yahya et al. found that the severity of OCD measured with Y-BOCS had a significant positive correlation with disability, but compulsion scores tended to have a weak negative correlation with disability scores; the correlation between disability and total Y-BOCS score, though positive, was not statistically significant.²⁵

The index study found that the obsession score significantly affected interpersonal activity and the work domain of IDEAS. Self-care was less affected, while communication was not at all affected. Compulsion scores significantly affected self-care, interpersonal activity, and work and did not affect communication. The Y-BOCS total score significantly affected all domains except communication. A study by Chaudhuri et al. found that work was the only domain of IDEAS that was significantly affected.¹⁶ Other studies have shown career disruption and disturbed interpersonal relations in OCD patients.^28,29 Another study by Calvocoressi et al. found that most of the causes for hospitalization in OCD subjects were disability-related, i.e., disruption of the home environment and poor self-care, etc.¹⁴ A study by Trivedi et al. also found that the severity of OC symptoms significantly affected work and communication with others.¹² Mancebo et al. also found that disability in the occupational sphere significantly hampers social and household functioning.³⁰ Therefore, it can be inferred that OCD also affects the work and interpersonal activities of the patients. This also gets reflected in our clinical practice as well, where we tend to see patients with marital and familial disharmony and much impairment in job/work. This should be taken into consideration while attempting behavior therapy for OCD patients where ongoing family problems may sabotage the effectiveness of the therapy.

The index study showed that, in the bipolar group, there was a significant positive correlation between the duration of illness and scores of disability in the communication, interpersonal activity, and work domain, which was similar to another study by Chacko et al. that showed a significant correlation between duration and communication and the work domain.³¹ Another study by Rosen et al. did not find any correlation between the duration of illness and functional outcome.³² In the OCD group, duration of illness significantly correlated with self-care, interpersonal activity, and work, which were in contrast to a study by Trivedi et al. that showed no significant correlation between duration and cognitive dysfunction due to OCD that led to disability.¹² Mohan et al. showed that disability in work was significantly more in OCD subjects with >5 years duration of illness than in subjects with 2–5 years duration.²² This reemphasizes the fact that, with time, both bipolar disorder and OCD tend to worsen with time in terms of disability if not taken proper care of.

While comparing both the groups, it was seen that bipolar subjects had significantly more disability in all domains of IDEAS and in the IDEAS global score compared to OCD subjects. This result is similar to the findings from other studies.^16,25 This finding would help us in prioritizing the allocation of resources and government funding for disability limitation and vocational rehabilitation for these two major mental disorders.

There were certain limitations of the index study. The study was conducted in the outpatient department of a tertiary care teaching hospital; hence, it cannot be generalized to community settings. The sample size in each group was small, which could have affected the power of the study. The sampling technique was purposive in nature, which might have resulted in selection bias.

CONCLUSION

Both bipolar disorder and OCD have serious disabling potentials. The index study found that the majority of the people in the bipolar group were moderate to severely disabled, whereas in the OCD group majority were mild to moderately disabled. It also found that bipolar subjects were more severely disabled compared to OCD subjects on the individual domain of the IDEAS as well as on the IDEAS global score. Among the domains of IDEAS, work was most significantly affected in the bipolar group, whereas communication was least affected by both obsession and compulsion in the OCD group. In both the groups, the duration of illness significantly correlated with most of the domains of IDEAS and IDEAS global score. To deal with disability, it is important to know the domains of daily functioning affected by these two disorders, which the index study attempted to address in a scientific manner.