Author's Accepted Manuscript

Effects of childhood trauma and clinicalfeatures on determining quality of life inpatients with bipolar I disorder

Evrim Erten, Aslı Funda Uney, Ömer Saatçioğlu,Armağan Özdemir, Nurhan Fıstıkçı, DuranÇakmak

PII: S0165-0327(14)00157-8DOI: http://dx.doi.org/10.1016/j.jad.2014.03.046Reference: JAD6659

To appear in: Journal of Affective Disorders

Received date: 8 October 2013Revised date: 13 February 2014Accepted date: 19 March 2014

Cite this article as: Evrim Erten, Aslı Funda Uney, Ömer Saatçioğlu, ArmağanÖzdemir, Nurhan Fıstıkçı, Duran Çakmak, Effects of childhood trauma andclinical features on determining quality of life in patients with bipolar Idisorder, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.03.046

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Effects of childhood trauma and clinical features on determining quality of life in patients with bipolar I disorder Running head: Childhood trauma and quality of life in bipolar I disorder Evrim Erten MD., Aslı Funda Kalkay MD., Ömer Saatçioğlu MD., Armağan Özdemir MD., Nurhan Fıstıkçı MD., Duran Çakmak MD. Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey. Corresponding author : Evrim Erten, MD Address : Dr. Evrim Erten Fulya mah. Akincibayir sok. 27/17 Mecidiyekoy-ISTANBUL, TURKEY E-mail : evrimerten@yahoo.com.tr Fax Number : +90 212 5706026 Word count: 4058 Aslı Funda Kalkay Uney, MD Esenyurt State Hospital, Istanbul, Turkey, Omer Saatcioglu, MD, Assoc. Prof. Bakırkoy Research and Training Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey, Armağan Özdemir, MD Bakırkoy Research and Training Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey Nurhan Fıstıkcı, MD Bakırkoy Research and Training Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey Duran Çakmak, MD, Prof. Istanbul AREL University, Psychology Department, Istanbul, Turkey

Background: We explored how childhood trauma (CHT) affects the clinical expression of

disorder and quality of life in patients with bipolar I (BP-I) disorder.

Methods: Euthymic patients (n=116) who subsequently received a diagnosis of BP-I disorder

were consecutively included and were interviewed using the following sociodemographic and

clinical data forms; Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale

(HDRS), Childhood Abuse and Neglect Questionnaire (CANQ) and the 36-item Medical

Outcome Study Short Form Health Survey (SF-36). The quality of life of BP-I patients with

and without a history of CHT were examined.

Results: The percentage of trauma was 61.2%. Patients who had CHT had higher

frequencies of depressive episodes (t= - 2.38, p=0.019), total episodes ( t= - 2.25, p=0.026 ),

attempted suicide more often (χ2 =18.12, p=0.003) and had lower scores on the pain subscale

of the SF-36 (z=-2.817, p=0.005). In patients with mixed or rapid-cycling episodes, SF-36

subscale scores except general health and pain were found to be lower.

Limitations: Our sample may fail to reflect the general BD population; the patients were

included consecutively and consisted of a majority of female patients.

Conclusions: CHT plays an important role in the clinical expression of BP-I disorder and

having mixed/rapid-cycling episodes negatively affects both physical and mental

components, as measured by the SF-36. While both males and females reported experiencing

sexual abuse, female BP-I patients complained about pain more often. It is suggested that

treatment of BP-I patients with a history of CHT should differ from that provided for patients

with no CHT history.

Key words: bipolar disorder – childhood trauma – quality of life – pain

1.Introduction:

Bipolar disorder (BD) is a complicated disorder characterized by manic, depressive and

euthymic states at both syndromal and subsyndromal levels. Quality of life (QoL) is defined

by the World Health Organization as individuals’ perceptions 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, standards and concerns. Once markers of QoL are thoroughly understood, new

approaches may be developed for treatment practices (Sachs and Rush, 2003). Reviews of

QoL in BD studies classify their purposes into four groups; 1) investigating QoL in different

mood phases, 2) comparing BD to other mental disorders, such as schizophrenia and unipolar

depression, 3) comparing bipolar patients with patients who have physical disorders, and 4)

comparing other psychometric features in BD (Namjoshi and Buesching, 2001; Michalak et

al., 2005). However, it has been stated that more studies of QoL in BD are required (Murray

and Michalak, 2012).

Studies have shown that the deterioration in Health Related-QoL (HRQoL) in BD is

similar to that of unipolar depression and greater than that of other chronic medical

conditions (Michalak et al., 2005; Dean et al., 2004). Negative precursors of QoL in patients

with BD include the presence of depressive signs (Vojta et al., 2001; Russo et al., 1997;

Yatham et al., 2004; Sierra et al., 2005), an increase in the number of depressive episodes

(MacQueen et al., 2000) and female patients (Gazalle et al., 2005; Ishak et al., 2012).

A study of veterans with BD found that a history of child abuse increased the tendency to

develop post-traumatic stress disorder (PTSD), panic disorder and alcohol use disorder, that

the number of major depression episodes increased with lower SF-36 (QoL) mental scores,

PTSD and alcohol use disorder, and that risk of suicide attempts due to depression increased

in patients with a history of physical and sexual abuse (Brown et al., 2005). Furthermore,

physical and sexual abuse in children were found to be associated with the early onset of BD,

longer manic or depressive episodes, a rapid-cycle course and a higher likelihood of suicide

attempts and substance abuse (Brown et al., 2005; Kupka et al., 2005; Leverich et al., 2002;

Leverich and Post, 2006; Garno et al., 2005; Etain et al., 2008; Etain et al., 2013). Other

studies have found that child sexual abuse was not related to suicide attempts or the number

of suicide attempts (Gao et al., 2009; Maguire et al., 2008).

A recently published review of studies investigating the relationship between child sexual

abuse and BD reported that while child sexual trauma could cause a more severe form of BD,

evidence relating to this issue may be insufficient and disputable (Fisher and Hosang, 2010;

Maniglio, 2013). Mixed episodes and rapid-cycling are two of the difficulties in the treatment

of BD (Garcia-Amador et al., 2009; González-Pinto et al., 2009). Few studies have

investigated the effects of childhood trauma (CHT) on QoL in BD. Therefore, aim of this

study was to investigate the relationship between childhood trauma and course of bipolar

disorders and to evaluate the relationship between childhood trauma and quality of life as

measured by QoL in bipolar disorders.

2.Methods

2.1 Participants

We attempted to study a sample of bipolar patients between January 2009 to June 2009 at the

Bakırköy Research and Training Hospital for Psychiatric and Neurological Diseases,

Istanbul, Turkey. One hundred sixteen consecutive euthymic patients who agreed to

participate in the study were included. Informed consents were obtained from all patients.

The ethical committee of the hospital approved the study.

2.2 Diagnostic assessment

Patients were diagnosed based on the diagnostic criteria of DSM-IV. Exclusion criteria were

illiteracy, mental retardation, dementia and/or other organic mental disorders, and being

under 18 years of age or over 65 years of age and having a comorbid chronic medical illness.

All patients who were scored lower than 5 points on the Young Mania Rating Scale

(YMRS) and below 7 points on the Hamilton Depression Rating Scale (HDRS) were

considered as euthymic .

2.3 Measurements

Patients completed a sociodemographic data form (age, sex, marital status, employment etc.)

and a clinical data form (age of onset, duration of disorder, features of the first episode of

disorder, number of lifetime depressive and manic episodes, suicide attempts, relatives’

psychiatric disorder history, questions determining whether at least one mixed episode or

rapid-cycling had been experienced). Previous medical records were also used to gather

information. Suicide attempts requiring hospitalization were considered as data.

Hamilton Depression Rating Scale (HDRS). The 17-item Hamilton Depression Rating

Scale originally published by Hamilton (1960) is the most commonly used scale for rating

and evaluating the severity of depression .It is not a diagnostic scale, but is used to monitor

the course of depression, with a focus on somatic complaints. Each item is rated from 0 to 4,

and the highest possible total score is 53. Williams developed a new version of the HDRS to

improve the interrater reliability (Structured Interview for Hamilton Depression Rating Scale-

21) (Williams, 1978). The reliability and validity of the Turkish version were assessed in

1996. (Akdemir et al., 1996). A score of ≤ 7 is recommended as the cutoff for defining

remission and can also be used in after-treatment groups and in normative samples

(Zimmerman et al., 2004).

Young Mania Rating Scale (YMRS). YMRS was developed in 1978 to measure the

severity of mania. Although a variety of other scales have been developed to measure mania,

the YMRS remains the most commonly used in clinical studies. It is an 11-item scale, with

each item rated for five levels of severity (Young et al., 1983). Reliability and validation

studies for the Turkish version of this scale were carried out in 2002 (Karadağ et al., 2002).

Childhood Abuse and Neglect Questionnaire (CANQ). CANQ contains 11 questions and

this questionnaire was developed to assess four dimensions of childhood trauma exposure

before age of 18 (emotional, physical and sexual abuse, and emotional or physical neglect)

(Yargic et al., 1994). If the patient gives an answer as ‘yes’ to the question, there will be

another part for what age this was happened and who did this and the number of times that

the patient was being exposured to trauma. All the patients who gave an answer as ‘yes’ were

interviewed by the first two investigators. This questionnaire also includes two items about

suicide and self-destructive behavior . In physical abuse part, injuries such as bruises, welts,

burns, abrasions, lacerations, wounds, cuts, bone and skull fractures, and other evidence of

physical injury are investigated. In sexual abuse part, from those involving relatively

nonspecific charges of assault to more specific ones as fondling or touching in an obscene

manner, sodomy, incest, and so forth are investigated. Situations involving no contact and

sexual games based on exploration between children of the same age were excluded from the

evaluation of sexual abuse. In neglect part , a judgement that the parents’ deficiencies in child

care are beyond those found acceptable by community and professional standards at the time

was inquired. These cases reported extreme failure to provide adequate food, clothing,

shelter, and medical attention in their childhood.

Short Form-36 (Medical Outcome Study 36-item Short Form Health Survey; SF-36). The

SF-36 was used to determine the patients’ QoL. It was developed and published by Ware and

Sherbourne, Rand Corporation, in 1992 to measure QoL, and is the most commonly used

scale for this purpose. It is rated by the individual, based on their status over the past four

weeks (Ware and Sherbourne, 1992), and is divided into eight sections: physical functioning

(10 items), social functioning (2 items), role limitations due to physical problems (4 items),

role limitations due to emotional problems (3 items), mental health (5 items), vitality (4

items), pain (2 items) and general health perception (5 items). Subscale health scores range

from 0 to 100; poor health status is scored 0 while good health status is scored 100. The total

score is calculated by combining the eight subscales. The survey was translated into Turkish

(Aydemir, 1999), and reliability and validation studies were carried out (Kocyigit et al.,

1999). It was standardized for the Turkish population (Demiral et al., 2004).

The BP-I group was divided into two groups: patients with and patients without a history

of childhood trauma. Sociodemographic and clinical features and SF-36 subscale scores were

compared between the groups. Additionally, sociodemographic and clinical features

predicting SF-36 were studied in all patients.

Statistical analysis

NCSS 2007 and PASS 2008 Statistical Software (Utah, USA) and SPSS 16.0 (SPSS

For Windows, Chicago, USA) were used for the statistical analyses. Descriptive statistics

(average, standard deviation, frequency) were used to assess the datas. The comparisons of

the parameters with a normal distribution were conducted with the Student's t-test, and the

Mann– Whitney U test was used for the comparisons of parameters without a normal

distribution. To avoid a Type I error, when performing multiple comparisons, we determined

the statistical significance in the bivariate analyses at p < 0.006 using a Bonferroni correction

as α=0.05/8=0.006. First the single-variable linear regression analysis was performed in

order to obtain the variables which were going to be included in multivariable regression

model to predict the SF-36 scale. In these analyzes, variables that showed p <0.20 level of

significance were included in the multivariate linear regression analysis. Correlation of

prediction between the SF-36 scale (dependent variable) and independent variables was

studied using stepwise regression analysis. Results were evaluated using a confidence interval

of 95% and significance level of p < 0.05.

Results

Sociodemographics and clinical variables

One hundred sixteen patients with a BP-I disorder diagnosis were included in the study.

Sociodemographic and clinical variables are presented in Table 1.

Childhood trauma history and its effect on BP disorder

More than half (61.2%) of the patients (n = 71) had at least one type of CHT history. Of

these, 25.9% (n = 30) experienced physical abuse in childhood or adolescence, 26.7% (n =

31) experienced emotional abuse in childhood or adolescence, 11.2% (n = 13) experienced

sexual abuse by a stranger, 9.5% (n = 11) experienced sexual abuse by relatives in childhood

or adolescence and 39.7% (n = 46) were neglected physically or emotionally in childhood or

adolescence (Table 2).

Patients with BD were divided into two groups according to CHT experience, and no

differences were found between groups in sociodemographic features. In our study, when

patients with BD were divided into two groups according to whether or not they had

experienced CHT and evaluated for their clinical features, patients with history of CHT were

found to have had more depressive ( t = –2.38, p = 0.019) and total episodes (t = –2.25, p =

0.026). There was no statistically significant difference between the two groups in terms of

age of onset of disorder, duration of disorder and total experienced manic, hypomanic or

mixed episodes.

Comparison of type of CHT history between the genders revealed no significant

differences (p > 0.05). History of CHT was detected in 45 (63.4%) of the 71 female patients

and 26 (57.8%) of the 45 male patients. Subtype evaluation of CHT revealed a significant

divorce rate among those patients with a history of intrafamilial sexual abuse (χ2 = 8.15, p =

0.017), and the type of first episode was often mania (χ2 = 10.09, p = 0.018). The rate of

physical abuse was found to be significantly higher in patients with a psychiatric disorder

history in their immediate family (χ2 = 4.06, p = 0.044).

A significant correlation was detected between CHT (any type) and suicide attempt (χ2 =

18.12, p = 0.003). With regard to CHT subtypes, significantly more patients with a history of

physical abuse (χ2 = 24.07, p = 0.0001), emotional abuse (χ2 = 19.35, p = 0.002),

intrafamilial sexual abuse (χ2 = 12.73, p = 0.026) and abuse by a stranger (χ2 = 21.24, p =

0.001) had made suicide attempts than patients with other types of trauma.

Childhood trauma history and its effect on QoL of BP patients

With regard to QoL, physical functioning, pain, general health, vitality, social functioning,

emotional role problems and mental health scores were found to be lower in patients with a

history of CHT than in patients without history of CHT, but to avoid a Type I error when

performing multiple comparisons, we placed the statistical significance in the bivariate

analyses at p < 0.006 using a Bonferroni correction as α=0.05/8=0.006. According to this

analyse, pain subscale scores were statistically significant among BP patients who had

childhood trauma. (Table 3)

Variables associated with QoL subscales

When variables affecting SF-36 scores across the whole BD group were evaluated, regression

analysis showed 11% (R² =0.110, B= -13.168, std. Error: 3.691, β =-0.306, t=- 3.568, 95%

CI=-20.480 – -5.86, p=0.001), of the variance in SF-36 Social Functioning, 13% (R² =0.136,

B= -28.486, std. Error: 6.72, β = -0.369, t= - 4.239, 95% CI= -41.798 – -15.173 ,

p=0.001),of the variance in SF-36 Emotional Role Problem, 8% (R² =0.086, B= -13.168, std.

Error: 3.225, β = -0.298, t= - 3.426, 95% CI= -17.442 – -4.662, p=0.001) ,of the variance in

SF-36 Physical Health and 15% (R² =0.153, B= -15.089, std. Error: 3.284, β =-0.386, t= -

4.595, 95% CI= -21.594 – -8.583, p=0.001) , of the variance in SF-36 Vitality subtype were

explained by mixed episode or rapid-cycle course of disorder. In each of the SF-36 general

health and mental health subscales, 18% ( for general health; R²= 0.184, B= -5.746, std.

Error: 1.381, β = -0.367, t= - 4.160, 95% CI= -8.483 – -3.009, p=0.001; for mental health ;

R²= 0.181, B= -3.213, std. Error: 1.153, β = -0.267, t= - 2.788, 95% CI= - 5.497 – -0.929,

p=0.006) , of the variance was explained by the number of mixed episodes. Seven (R²=

0.072, B= -9.743, std. Error: 4.124, β =-0.208, t=- 2.363, 95% CI= -17.913 – -1.573,

p=0.02) , percent of the variance in the SF-36 pain subscale was determined by sexual abuse

(Tables 4–6).

Discussion

Our study showed that childhood traumatic events are associated with a more serious

form of illness, greater proness to depressive episodes, more suicidal attempts and more total

number of episodes which are consisted with previous studies (Leverich et al., 2002; Garno et

al., 2005). It has also been reported that these patients were more commonly female (Neria et

al., 2002, Conus et al., 2010, Meade et al., 2009), had more depressive episodes (Neria et

al., 2002) and mixed episodes (Meade et al., 2009), and manifested more depressive

symptoms between the episodes (Maguire et al., 2008). The proportion of our patients with at

least one type of CHT history was 61.2%, which is within the range (45–68%) specified for

BD in the literature (Leverich et al., 2002; Garno et al., 2005; Neria et al., 2002; Etain et al.,

2013 ). Another recent study found the prevalence of any type of childhood psychosocial

stress factor in first episode BP-I patients to be 80% (Conus et al., 2010). The majority of the

patients included in our study were female (61.2%). This may have been because of

recruiting the patients in our study consecutively, and that 55.2% of the patients had rapid-

cycling and mixed episodes as they are more commonly seen in female patients (Tondo and

Baldessarini, 1998; Arnold et al., 2000; Arnold, 2003; Kessing, 2004, Suppes et al., 2001).

While our finding that there was no difference between the two genders in terms of CHT

subtypes is consistent with some studies (Garno et al., 2005; Maguire et al., 2008), others

report that sexual abuse is more commonly seen in female patients (Brown et al., 2005;

Leverich et al., 2002; Conus et al., 2010).

The relationship found between having experienced intrafamilial sexual abuse and being

divorced in our study suggests that being a survivor of intrafamilial sexual abuse makes it

harder to maintain close relationships in adulthood. One study reported that BD patients who

have experienced any type of trauma in their lifetimes are more depressive and have

difficulty maintaining interpersonal relationships, as well as being anxious and intrusive

(Maguire et al., 2008). It was concluded that higher CTQ scores were associated with the

suicidal behavior in BD (Leboyer et al. ,2007).

Our finding of a significant relationship between surviving intrafamilial sexual abuse and

having mania as the first episode may be relevant as it shows how CHT subtypes affect the

onset of BP-I disorder. In one study; where sexual abuse and physical abuse were evaluated

together and the prevalence of these types of abuse in patients hospitalized with the diagnosis

of psychotic mania for the first time were found to be significantly high (Conus et al., 2010).

Our finding of a significant association between having a family member with a history of

psychiatric disorder and being a survivor of physical abuse suggests that patients with BD

have a higher risk of experiencing physical violence in the family. It was reported that

patients with BD and a history of CHT had lower functionality, and were more often involved

in criminal cases (Weili et al., 2008).

In our BP-I group, pain in patients with a history of CHT was found statistically

significant lower than in patients without a history of CHT. Other subscales of SF36 scores

were also lower but no statistical significance. Sexual abuse, female gender and number of

total episodes were also related with pain in the all BP-I patients. It was reported that women

with bipolar disorder had worse physical HRQOL, which might be explained by increased

self-reported pain (de la Cruz et al., 2013) and they had concomitant cronic pain problems

with depressive symptoms (Miller et al., 2013, Failde et al., 2013, ). The majority of patients

(61%) was female but we didn’t find any difference between type of CHT history and gender.

A review article reported that regardless of gender, sexual abuse plays a role in chronic pain

complaints (Arnow, 2004). There has been growing evidence for correlation between

childhood abuse and adult health problems, such as long-term pain ( Finestone et al.,2000,

Walker et al., 1999, Davies et al., 2005). In a recent study where SF36 pain subscale was

used as a tool, it was found that CHT and current post traumatic stress disorder (PTSD)

symptoms predicted higher levels of functional impairment related to pain ( Powers et al.,

2013). It is also suggested for men that unresolved emotions related to abuse may have found

a more socially accepted or less stigmatizing way to be expressed, potentially through

increased pain perception or emotional response to pain ( Fillingimet al., 1999, Hooper and

Warwick , 2006). Our finding suggests that sexual abuse in both genders was related to pain.

Our study evaluated the childhood trauma history of patients with bipolar I disorder during

euthymic period and investigated its effects on the SF-36.We found that mixed episodes or

rapid-cycling and total number of episodes played a role in reducing physical health, general

health, physical role problems, vitality, social functioning, emotional role problems and

mental health scores. This finding is consistent with previous studies that have reported that

QoL is reduced in BD patients with current mixed episodes and depressive episodes and a

higher number of total episodes (Vojta et al., 2001, Mac Queen et al., 2000).

In the literature; the SF-36 has been used to compare bipolar patients to other patients

with physical disorders (Arnold et al., 2000), to compare depressive and euthymic episodes of

the disorder (Leidy et al., 1998), to evaluate the medications used to treat BD (Chand et al.,

2004; Namjoshi et al., 2002). The general health, social functioning, physical role and

emotional role scores in bipolar patients with depressive episode were lower than the scores

of patients with unipolar depression (Yatham et al., 2004).

Studies have reported that depressive symptoms and depressive episodes tend to cause

disability and dysfunction (MacQueen et al., 2000; Dias et al., 2008; Zhang et al., 2006;

Gutiérrez-Rojas et al., 2008), and as depressive symptoms were eliminated, HRQoL scores

improved as well (Hayhurst et al., 2006). In a study investigating the prevalence of

psychiatric disorders in a large population, 136 individuals were diagnosed with BD (93 BP-I

disorders, 43 BDs with not otherwise specified (NOS) and interviewed using the SF-36.

When compared with groups of patients with other psychiatric disorders, a significantly

lower QoL scores was detected in the BD group. For example, mean mental health scores

were lower in the BP-I group. Additionally, lower scores were obtained in the BP-I group

than the BD with NOS group for the emotional role problem, social functioning and pain

subscales (ten Have et al., 2002).Consistent with the aforementioned studies, we suggest the

presence of depressive symptoms in mixed and rapid-cycling episodes during the course of

the disorder to be associated with poorer prognoses in these groups.

Consistent with our study, others have reported the physical functioning score to decrease

as the age increases, which may be due to the accompanying medical conditions reported by

the patients (Fenn et al., 2005). BP-I patients with accompanying medical conditions were

excluded from our study. Therefore, this decrease may be directly associated with presence of

the BP-I disorder. Nevertheless, consistent with the findings of that study, we found that

mental health scores improved as the age increased. While there were no differences related

to suicide attempts in that study, we found the mental health and social functioning scores in

our study to be lower in patients attempting suicide. In another study, patients with and

without a history of suicide attempt were compared and scores of patients attempting suicide

were found to be low in all subscales (de Abreu et al., 2012).

A study assessing SF-36 in two main categories of physical health and mental health

found that an early age of onset of BP-I disorder was associated with a reduction in QoL

mental health scores (Gutiérrez-Rojas et al., 2008). When we considered the subscales of

both components, there was also a reduction in the physical role problem scores in our study.

Other studies have reported that an early age of onset (Suppes et al., 2001, Perlis et al., 2004,

Carter et al., 2003) and suicide attempts may be associated with a poor prognosis (Ahrens et

al., 1995).

Our study found that patients who had first-degree relatives with a history of mental

illness had high social functioning scores, suggesting that the presence of the disease in the

family does not affect the patient's social functioning and that it may increase social

acceptance.

The limitations of our findings need to be considered. Our sample may fail to reflect the

general BD population; because we included the patients consecutively, our sample consisted

of a majority of female patients, and patients who are more difficult to treat are frequently

referred to our regional hospital. Stigma, independence and familial support play a crucial

role in determining QoL, but these were not investigated in our study. We tried to explore

CHT history with Childhood Abuse and Neglect Questionnaire (CANQ). On one hand, this

could cause a potential measurement problem due to the retrospective recall of childhood

abuse and this may reduce the reliability of assessment; on the other hand the percentages

of abuse and neglect in our study were similar to other studies which were presented in the

review where CTQ was presented as a more reliable tool (Fisher and Hosang, 2010).

Nevertheless, we believe that our study provides relevant information about how sexual

abuse and clinical features jointly affect QoL subscales scores. We can conclude that even if

they are currently in a euthymic period which is one of the strength point of our study, bipolar

patients who were abused as children may have a higher number of disorder episodes,

depressive episodes and suicide attempts, and lower scores of pain. For bipolar disorder

patients especially for women, additional interventions that focus on the role of pain are also

needed in order to improve long-term outcomes. It was concluded that having mixed/rapid-

cycling episodes affects both the physical and mental components of the SF-36 scores. We

postulate that CHT may play an important role in the prognosis of BD, and thus appropriate

treatment strategies should be developed for bipolar patients with a history of CHT. In

conclusion, achieving improvements in QoL should be one of the main goals of BD

treatment, and it is recognized that longitudinal, prospective, periodical studies are required

to reveal the determinants of QoL.

 

 

 

 

Conflict of Interest

All the authors read and approved the manuscript. We don’t have any manuscript already

published from the study. All authors declare that we have no conflicts of interest. All authors

contributed to and have approved the final manuscript.

 

 

 

 

 

 

 

 

 

 

 

 

Contribution 

Detail of the each author with his/her contribution in this paper is as under:

Name of the author and e-mail ID Types of contribution

Evrim Erten, MD evrimerten@yahoo.com.tr

Designed the study, managed the literature

search and wrote the manuscript

Aslı Funda Kalkay Uney, MD

fundakalkay@hotmail.com

Collected the data and wrote the

manuscript

Omer Saatcioglu, Assoc. Prof. MD

osaatcioglu@superonline.com

Revised the manuscript

Armagan Ozdemir ,MD

armioz@yahoo.com

wrote the manuscript

Nurhan Fistikci, MD

nurhanfistikci@gmail.com

wrote the manuscript

Duran Cakmak, Prof., MD

cakmakduran@yahoo.com

Revised the manuscript

 

Disclosure: There’s no role of funding source in study design: in the collection, analysis

and interpretation of data; in the writing of the report; and in the decision to submit the paper

for publication. Our study was not partially or fully sponsored by any sponsoring agency.

Acknowledgment: There is no funding source in this study: in the collection, analysis and

interpretation of data; in the writing of the report; and in the decision to submit the paper for

publication.

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Table 1. Sociodemographic characteristics and clinical features of BP-I patients (n = 116)

Sociodemographic characteristics Age (years) 38.34 ± 8.46 Gender n (%) Female 71 (61.2) Male 43 (38.8) Marital status Single 31 (26.7) Married 59 (50.9) Separated 22 (19) Widowed 4 (3.4) Education level Primary school 56 (48.3) High school 40 (34.5) University 20 (17.3) Occupation Student/worker 42 (36.2) Unemployed 9 (7.8) Housewife 42 (36.2) Stay at home 14 (12.1) Retired 9 (7.8) Clinical features Suicide attempts 36 (31)Family history of psychiatric illness 37 (31.9) Type of first episode Mania 71 (61.2) Mixed 3 (2.6) Hypomania 1 (0.9) Depression 41 (35.3) Type of course Natural 52 (44.8) Rapid-cycling 18 (15.5) Mixed 34 (29.3) Rapid-cycling + mixed 12 (10.3) Mean ± SD Age of onset 23.15 (6.96) Duration of illness (years) 15.19 (7.37) Number of manic episodes 3.97 (3.25) Number of mixed episodes 0.84 (1.42) Number of depressive episodes 2.46 (3.06) Number of total episodes 8.63 (5.62)

Table 2. Types of childhood trauma (n = 116)

n %

Physical abuse 30 25.9

Emotional abuse 31 26.7

Sexual abuse (by a stranger) 13 11.2

Intrafamilial sexual abuse 11 9.5

Negligence (physical or emotional) 46 39.7

Table 3. Evaluation of SF-36 according to presence of childhood abuse

Childhood Abuse

t/Z p Absent (n = 45) Present (n = 71)

Mean ± SD Mean ± SD

++ Physical functioning 85.55±18.22

(90)

79.08±18.36

(80)

-2.191z 0.028

++ Physical role problem 74.44±35.14

(100)

64.43±35.52

(75)

-1.674 z 0.094

++ Pain 82.31±20.47

(84)

69.76±23.14

(70)

-2.817 z 0.005*

+General health

68.26±20.74 58.30±22.39 2.400t 0.018

+Vitality 63.77±15.63 55.63±21.11 2.380t 0.019

+Social function

80.83±17.39 71.83±23.11 2.240t 0.019

++Emotional role problem 71.11±32.25

(67)

54.92±41.05

(66)

-2.030 z 0.042

+Mental health 69.33±14.89 62.47±17.88 2.142 t 0.034 + Student t test ++Mann-Whitney U

*Significance level p<0.006 (Bonferroni correction: α=0.05/8=0.006)

Table 4. Results of stepwise linear regression analysis relating to SF social functioning and emotional role problem scores

of bipolar patients

Dependent

variable

Independent

variable R² F (df) B

Std.

error β t p CI

SF 36 Social

functioning

Step 3

Constant

8.476**

(3.112)

83.309 3.068 27.151 0.001** 77.229 89.388

Type of disorder

(mixed+rap.cycling) 0.110

–

13.168 3.691

–

0.306 –3.568 0.001**

–

20.480 –5.856

Suicide attempt 0.150 –

11.324 4.066

–

0.245 –2.785 0.006**

–

19.381 –3.267

Family history 0.185 8.760 4.009 0.191 2.185 0.031* 0.816 16.704

SF 36

Emotional

functioning

Step 1

Constant

17.967**

(1.114)

76.923 4.992 15.410 0.001** 67.035 86.812

Type of disorder

(mixed+rap.cycling) 0.136

–

28.486 6.720

–

0.369 –4.239 0.001**

–

41.798

–

15.173

* p < 0.05 ** p < 0.01

Table 5. Results of stepwise linear regression analysis relating to SF physical health, general health and vitality scores of

bipolar patients

Dependent

variable

Independent

variable R² F (df) B

Std.

error β t p CI

SF 36

Physical

health

Step 2

Constant

9.496**

(2.113)

107.82 7.712 13.981 0.000** 92.546 123.105

Type of disorder

(mixed+rap.cycling) 0.086

–

11.052 3.225

–

0.298 –3.426 0.001**

–

17.442 –4.662

Age 0.144 –0.525 0.190 –

0.240 –2.759 0.007** –0.902 –0.148

SF 36

General

health

Step 2

Constant

15.504**

(2.113)

73.465 3.394 21.646 0.001** 66.741 80.189

Number of mixed

episodes 0.184 –5.746 1.381

–

0.367 –4.160 0.001** –8.483 –3.009

Number of total

episodes 0.215 –0.746 0.349

–

0.189 –2.140 0.035* –1.437 –0.055

SF 36

Vitality

Step 2

Constant

14.291**

(2.113)

47.491 7.852 6.049 0.001** 31.936 63.047

Type of disorder

(mixed+rap.cycling) 0.153

–

15.089 3.284

–

0.386 –4.595 0.001**

–

21.594 –8.583

Age 0.202 0.512 0.194 0.222 2.642 0.009** 0.128 0.896

* p < 0.05 ** p < 0.01

Table 6. Results of stepwise linear regression analysis relating to SF pain and mental health scores of bipolar patients

* p < 0.05 ** p < 0.01

 

Dependent

variable

Independent

variable

R² F (df) B Std.

Error

β t p CI

SF 36 Pain

Step 3

Constant 7.692**

(3.112)

73.061 6.907 10.577 0.001** 59.375 86.748

Sexual abuse 0.072 –9.743 4.124 –

0.208

–2.363 0.020* –

17.913

–1.573

Gender (F) 0.122 11.149 4.040 0.238 2.760 0.007** 3.145 19.153

N of total episodes 0.149 –0.920 0.359 –

0.226

–2.563 0.012* –1.632 –0.209

SF 36

Mental

health

Step 4

Constant 11.047**

(4.111)

67.396 3.510 19.203 0.001** 60.411 74.350

N of mixed episodes 0.181 –3.213 1.153 –

0.267

–2.788 0.006** –5.497 –0.929

Type of disorder

(mixed+rap.cycling)

0.221 –7.794 3.260 –

0.228

–2.390 0.019* –

14.254

–1.333

Duration of

disorder

0.249 0.458 0.188 0.198 2.431 0.017* 0.085 0.830

Suicide attempt 0.285 –7.065 3.009 –

0.193

–2.348 0.021 –

13.027

–1.103