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Year : 2022  |  Volume : 31  |  Issue : 2  |  Page : 318-324  Table of Contents     

Psychiatric comorbidity and quality of life in patients with bipolar disorder

1 Department of Psychiatry, ABVIMS and Dr RML Hospital, New Delhi, India
2 Department of Psychiatry, Maulana Azad Medical College and GIPMER, New Delhi, India

Date of Submission02-Feb-2021
Date of Acceptance15-Jul-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Gunja Sengupta
Department of Psychiatry, Gate No. 9, ABVIMS and Dr RML Hospital, Baba Kharak Singh Marg, New Delhi - 110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_24_21

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Background: Psychiatric comorbidity in patients with bipolar disorder (BD) has been associated with an earlier onset, rapid cycling, worsening severity and outcome, and increased suicidality. Patients with BD have been reported to have poor quality of life (QOL) even during remission. Aims and Objectives: Estimate the prevalence of psychiatric comorbidity and assess the QOL in patients with BD, and find the associated sociodemographic and clinical variables. Materials and Methods: This cross-sectional study was done in a general hospital psychiatric unit on 100 patients (both inpatients and outpatients) with DSM-IV-TR BD in partial or complete remission. Patients were assessed using a semi-structured pro forma, Mini International Neuropsychiatric Interview 6.0 - Hindi version, Hamilton Rating Scale for Depression or Young Mania Rating Scale and World Health Organization QOL instrument, short-form (WHOQOL-BREF), Hindi Version. Results: Sixty-one percent of the sample had at least one psychiatric comorbidity, and the commonest comorbid disorders were substance use disorders (SUD) (30%) and anxiety disorders (AD) (28%). Male gender was identified as a predictor for comorbidity in BD. The mean QOL-BREF score was 85.96 ± 14.35. Poor QOL was associated with older age at onset of comorbidity, multiple comorbidities, mixed episodes, rapid cycling, partial remission, and increased severity of depression while patients with current hypomanic symptoms were found to have better QOL. BD with comorbidity had worse QOL than those without comorbidity.Conclusion: The majority of patients with BD had at least one comorbidity. SUD were the most common comorbid disorders. QOL, already poor in BD patients, was poorer in cases with comorbidity.

Keywords: Bipolar disorder, comorbidity, quality of life

How to cite this article:
Sengupta G, Jena S. Psychiatric comorbidity and quality of life in patients with bipolar disorder. Ind Psychiatry J 2022;31:318-24

How to cite this URL:
Sengupta G, Jena S. Psychiatric comorbidity and quality of life in patients with bipolar disorder. Ind Psychiatry J [serial online] 2022 [cited 2023 Jan 28];31:318-24. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/2/318/348364

Bipolar disorder (BD) is a type of mood disorder characterized by periods of depressive and manic symptoms that occur alternately or simultaneously with one another with or without psychotic symptoms with intervening periods with or without major mood symptoms.[1]

There have been two types of prevalence described in the prevalence studies of comorbidity based on the structured interviews: “Lifetime prevalence” is the proportion of the sample who ever experienced a disorder, while “Current prevalence” is the proportion who experienced the disorder at some time in the 12 months before the interview or as per the duration specified.[2] In a significant amount of scientific literature, it has been seen that comorbidity is the rule rather than the exception in the case of bipolar spectrum disorders, of both psychiatric and medical illnesses, which leads to worsening of quality of life (QOL), increasing mortality and poses significant treatment challenges.[3]

Psychiatric comorbidity in BD has been associated with poorer course specifiers of the disease, including earlier age at onset of affective symptoms, rapid cycling, worsening severity of episodes over time, poorer overall outcome, high rates of suicidality, and less favorable response to lithium.[4]

From the early 1990s, comorbidity was studied in bipolar I patients and was found to be between 50% and 70%.[2],[5],[6],[7],[8] Both the specific studies for comorbidity as well as the epidemiological studies on BD had estimates of comorbidity in about half to three-quarters of patients with BD,[5],[6],[7],[8],[9],[10],[11] the wide range probably due to differences in instruments used, varying criteria, different permutations and combinations of lifetime and current comorbidity, and cultural/ethnic/socio-demographic differences in the samples.

The World Health Organization (WHO) describes QOL as “a broad-ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, personal beliefs, and their relationship to salient features of their environment.”[12]

QOL has been seen to be colored by an individual's current affective state, whether that is to be discounted or not is debatable. Almost unequivocally, literature has shown that patients with BD have deficits in QOL even in periods of remission,[13],[14],[15],[16] especially when associated with comorbidity.[16],[17] Furthermore in BD, poorer QOL has been seen to be associated with the depressive end of the spectrum rather than the manic.[15],[16],[17] Certain comorbidities were seen to be contributing to poorer QOL scores in BD patients.[16],[17]

This study was done to estimate the prevalence of psychiatric comorbidity in patients with BD and find the association between sociodemographic and clinical variables and QOL reported by patients with BD, and see how comorbidity affects the QOL in patients with BD.

   Materials and Methods Top

This was a cross-sectional study conducted in a general hospital psychiatric unit (both OPD and IPD) of a tertiary care general hospital in New Delhi from January 2017 to March 2018 with 100 patients diagnosed with BD (as per the DSM-IV-TR criteria)[18] attending the Psychiatry OPD or admitted to the psychiatry inpatient unit. The study was approved by the institutional ethics committee.

Patients with BD of age between 18 and 65 years, whose current episode was in either full remission or partial remission (as per the DSM-IV-TR remission/partial remission criteria)[18] and gave informed consent were recruited for the study. The minimum and maximum duration of BD taken were 1 and 10 years, respectively. Patients excluded were those having clinically severe cognitive deficits, those having impaired insight, those who were uncooperative, those with hearing or visual impairment, intellectual disability assessed clinically, and patients with chronic debilitating physical illness, with complications requiring hospitalization for the same.

All patients with BD who fulfilled these inclusion and exclusion criteria gave informed consent and underwent the following:

  • Information collection as per the semi-structured pro forma (prepared for this study)
  • Interview as per the Mini-International Neuropsychiatric Interview (MINI) 6.0 Hindi version[19] for screening for comorbidity
  • Administration of Hamilton Rating Scale for Depression (HAM-D)[20] in case of current depressive episode and Young Mania Rating Scale (YMRS)[21] in case of current manic episode to assess severity
  • Administration of WHO QOL instrument, short-form (WHOQOL-BREF)-Hindi version[22] for measuring QOL.

The data so acquired were tabulated in Microsoft Excel and analysis was performed using Statistical Package for the Social Sciences (SPSS) version 16.0 software [IBM SPSS Statistics v16, Chicago, IL].

Qualitative variables were compared between groups using Chi-square/Fisher's Exact Test. Quantitative variables were compared using Kruskal–Wallis/ANOVA (for >2 groups) and Unpaired t-test/Mann–Whitney Test (for 2 groups). Spearman's correlation was applied for the association between QOL and number of episodes, number of comorbidities, frequency of episodes in last year, YMRS and HAMD scores. Multivariate Logistic regression was used to identify possible predictors for comorbidity. A P < 0.05 was considered statistically significant. The total scores of QOL-BREF were calculated. The total score for each of the 4 domains (Physical health, Psychological, Social Relationships, and Environment) were calculated and the scores of each of the domains were converted into transformed scores, equivalent to the corresponding domains of WHOQOL-BREF and WHOQOL-100, and transformed scores to WHOQOL-100 were used for further analysis.

   Results Top

The data of hundred patients with BD were analyzed. The majority were males (78%), the mean age being 34.76 years. The majority were married (54%), unemployed/dependent (30%), belonging to the urban background (85%), and urban upper-lower socioeconomic status (SES) (39%). Ninety-six percent of patients had BD-I as their diagnosis. The mean age at onset of BD was 28.89 years, their illness spanning a course of around 5 years on an average (68.86 ± 38.88 months), average duration of symptomatic illness being 16.22 ± 11.83 months, with multiple episodes (4.37 ± 2.88), with an average of 1.34 ± 1.84 hospital admissions for BD through the course of their illness The majority had an episode of mania (68%) as their last episode. The mean duration of the last episode was 3.53 ± 3.92 months. The patients had experienced an average of 1.07 ± 0.86 episodes in the last year. The majority were assessed at full remission (51%) and as an OPD follow-up (87%). Only 5% of the sample had rapid cycling.

Sixty-one (61%) patients were found to have at least 1 comorbidity. Out of 61 patients with comorbidity, 37 (61%), 14 (24%) and 10 (16%) have had one, two or more and three or more comorbidities, respectively. The two of the commonest comorbid group of disorders were substance use disorders (SUD) (30%) and AD (28%). The commonest comorbid disorder was tobacco use disorder (29%). The other comorbid disorders in decreasing order of prevalence were suicidality (20%), agoraphobia (15%), panic disorder (11%), social anxiety disorder (9%), alcohol dependence/abuse (8%), cannabis dependence/abuse (3%), generalized anxiety disorder (2%), posttraumatic stress disorder (2%), and obsessive-compulsive disorder (1%).

A multivariate logistic regression using stepwise model selection criteria was performed to find out the best predictors for comorbidity [Table 1].
Table 1: Predictors of comorbidity

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The following variables were included in the analysis: age, sex, SES, marital status, family history of psychiatric illness, family history of affective disorder, premorbid personality, age of onset, and the total duration of illness (TDI). The best model was arrived at in one step with explanatory power (R2) of 4.6% wherein only gender (male) was found to be significant.

Clinical variables having an association with the presence of comorbidity are summarized in [Table 2]. The total and individual domain scores of QOL are summarized in [Table 3]. The clinical correlates of QOL and its domains are summarized in [Table 4], [Table 5], [Table 6].
Table 2: Association of comorbidity with clinical variables

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Table 3: Scores of World Health Organization quality of life-BREF and World Health Organization quality of life-100

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Table 4: Association of quality of life with continuous demographic and clinical variables

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Table 5: Association of quality of life with number of episodes, number of comorbidities, frequency of episodes in the last 1 year, Young Mania Rating Scale and Hamilton Rating Scale for Depression scores

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Table 6: Association of quality of life with categorical clinical variables and comorbidity

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   Discussion Top

The prevalence of at least one comorbidity was found in 61% of patients with BD. It was similar to the Stanley Bipolar Network study[6] and a recent study by Loftus et al.[8] which found the prevalence of 67% and 59% respectively, but more than the estimates of the study done by Vieta et al. in 2001[7] which revealed a prevalence of 35% and an Indian study by Munoli et al. in 2014[11] found the prevalence of 43%. The Western studies[6],[7] mentioned took Composite International Diagnostic Interview (CIDI) or Structured Clinical Interview for DSM Disorders (SCID) as the tool for the assessment of comorbidity which has more categories for lifetime comorbidity as compared to MINI that was used in this study. However, the disorders in all these studies were based on criteria of either DSM IV or DSM IV-TR. The study by Munoli et al.[11] was retrospective in design while other studies were of prospective design.

Among the categories of comorbidity, SUD were the most common category (30%) among which the most common substance used was tobacco (29%), followed by alcohol (8%) and cannabis (3%). No other substance use was found in the sample. Although the overall prevalence was similar to the clinical studies both in India[11] as well as in the Western populations[6],[7],[16],[23] (19–42%), the distribution of individual SUD was widely different. The previous studies using CIDI and SCID did not take into account tobacco use, which was the most common (29%) substance found in our study. There were no patients with BD found to have used any other substance apart from the above-mentioned 3 substances, which is unusual and may have been due to under-reporting of the patients due to it being a social and religious taboo in our culture. The second most common category in our study was anxiety disorders (AD) (28%). Since the AD were “current” in our study, the prevalence rates were comparable to studies identifying current comorbidity.[5],[9] But was much lower than the estimates of lifetime comorbidity found in these studies. A recent review by Spoorthy et al.[24] found current and lifetime prevalence rates of AD to be 35–38% and 41–47%, respectively. The third-most common category in our study was suicidality (20%). There were no studies that considered suicidality as comorbidity as most studies used CIDI or SCID as an instrument that did not have this category. There were no patients with BD in the sample who had comorbidity for eating disorder, which is in contrast to the Western literature which had estimates of this comorbidity of around 6%,[6] the reason for which might be that the prevalence of eating disorders is very low in Indian population.[25]

On analysis for clinical correlates in the sample, the presence of comorbidity had a significant association with the presence of suicide attempts and psychotic symptoms [Table 2], i.e. the patients with BD with comorbidity are more likely to attempt suicide and have psychotic symptoms during their illness than the ones without comorbidity, this is in concurrence with the outcomes of the studies by Vieta et al.[7] However, our study found no significant association of the presence of comorbidity to the age at onset of BD (P = 0.093), the TDI (P = 0.076), the total duration of symptomatic illness (P = 0.093), the total number of episodes (P = 0.153) and the total number of admissions (P = 0.359), and rapid cycling [Table 2] as found in the above-mentioned studies. There was a significant association between the presence of comorbidity and the presence of psychotic symptoms which does not concur with the findings of the study by Vieta et al.[7] which found no such association.

These differences may be since the populations under study had different sociocultural profiles and social support and that may influence the treatment-seeking, compliance, and need for hospital admissions and our data had limited samples with rapid cycling which may have led to the differences in the result.

In our sample, the only variable found to have significance as a predictor of comorbidity, in general, was the male gender. Of the studies that mentioned gender as a correlate, one[7] showed no significant association between gender and comorbidity and another[26] stated that females have more comorbidity in all disorders except substance use. The difference may be due to the difference in the sociodemographic profile of the population under study.

Since there is no known cut-off in WHO-QOL scores, scores were compared to the data of the field trial report of WHO-QOL-BREF of New Delhi[20] which revealed poorer total scores in BD in partial or full remission, and specifically in domains of Physical health, Psychological and Social relations; and scores were better in the domain of Environment. These findings were in line with the majority of studies of BD patients on the QOL, in India as well as abroad, in which it has been a finding that BD patients have a poorer QOL even in periods of remission.[13],[14],[15],[16]

The patients with BD having an older onset of comorbidity had significantly poorer total scores in WHO-QOL-BREF as well as significantly lower values in physical health and environment [Table 4] and [Table 5]. There were lower scores in the domains of physical health and psychological based on the last episode with the poorest values if the last episode was mixed followed by depressive episode, [Table 6]. Patients with BD with a higher number of mixed episodes had lower scores in total as well in individual domains except Social relationships. Those with a higher number of hypomanic episodes had better scores in the domain of environment. Those with rapid cycling BD showed significantly worse scores on the domain of physical health as compared to those without rapid cycling. The scores in the domain of social relationships were poorer in those with partial remission than those with full remission [Table 6]. Increasing HAM-D scores were associated with significantly poorer scores in total as well as all 4 domains of QOL [Table 5]. This is in concurrence with results from earlier studies wherein the presence of depressive symptoms was associated with poorer QOL.[15],[16]

The available literature shows associations of poorer QOL with the length of illness[13] (or early-onset), and length of the symptomatic period,[13] which was not found in this study. Though the literature on this topic is equivocal as Özer et al.[26] found that none of the historical variables (including the age at onset, number of episodes, duration of illness, number of hospitalizations) was associated with lower QOL scores. This study was done on a Turkish population and was a cross-sectional study with 100 patients with BD like this study.

With regards to comorbidity, it was seen that the presence of comorbidity, the presence of AD as comorbidity, the number of comorbidities, and the age at onset of comorbidity had a significant association with poorer QOL. This denotes that the presence of comorbidity in BD leads to low quality of physical and psychological health as well as of the environment that he or she is in. However, probably due to the structure of families and relationships in a country like India, it does not affect the social relationships of the patients with BD. This is in concurrence with the study by Kilbourne et al.[17] which had worse QOL in patients with BD with co-occurring psychiatric conditions. Among specific categories of comorbidity, the presence of AD led to significantly poorer scores of QOL, both in the total score as well as on domain scores except the Social relationships domain. This is in concurrence with the available literature wherein the presence of anxiety symptoms/disorder leads to poorer QOL.[17] However, the presence of SUD did not lead to any significant changes in QOL over and above those without the comorbidity. This is similar to the findings of Sylvia et al.[16] which found that psychiatric comorbidities except SUD led to poor QOL, but in contrast to the findings of Kilbourne et al.[17] who concluded that illicit drug use has an association with QOL maybe because the methodology of that study-path analysis, was widely different from this study. QOL was perceived to be poorer in all domains except for the Social relationships domain in patients with BD with moderate suicidality as compared to those with mild suicidality. This aspect has not been apparent in available literature as the instrument used for comorbidity studies has almost exclusively been CIDI/SCID, which does not have suicidality as comorbidity. However, a study by Anyayo et al.[27] showed that the poor QOL in patients of BD was associated with the history of suicidal thoughts.

   Conclusion Top

This study found that comorbidity is a rather important aspect of BD, the prevalence of it being almost two-thirds of the sample, the main categories being that of SUD and AD, occurring more in males than in females. Patients with BD with comorbidity are more likely to attempt suicide and psychotic symptoms during their episodes than the ones without comorbidity. QOL was poorer in patients with BD even during periods of remission or partial remission, which worsened with older age of onset of comorbidity, increasing numbers of comorbidity, mixed episodes, rapid cycling, partial remission, and HAMD scores. However, the QOL was better in patients who have had current hypomanic symptoms and more hypomanic episodes. BD patients with comorbidity have had worse scores of QOL than those without comorbidity, especially ones with AD. As the QOL is poor in BD patients with psychiatric comorbidity a thorough assessment is necessary to diagnose a comorbid condition so that appropriate management is done.


Our sample size was small and the study was cross-sectional in design. As the sample was taken from patients attending a Psychiatry OPD our study findings cannot be generalized to the population of Delhi NCR. A longitudinal study with a bigger sample size from the community is warranted.


Dr. PS Biswas, Dr. Mahima Kapoor, Dr. Anurag Jhanjee, Dr. Amandeep Goyal (faculty members), all senior residents and junior residents of the Department of Psychiatry, GIPMER, for their invaluable support during the development of the protocol and conduct of the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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