ABSTRACT: Despite modern treatments, bipolar disorder remains a chronic, relapsing disorder that leads to long-term psychosocial disability. A review of the literature suggests that while employment rates amongst individuals with bipolar disorder may improve over time, and are relatively better compared to some other chronic mental disorders, employment prospects do not match the high scholastic achievements seen amongst this group of people before the onset of their illness. For those with bipolar disorder, clinical recovery does not necessarily mean functional recovery, and the usual early age of onset may further reduce an individual's preparedness for employment. Two brief vignettes are used to discuss how occupational therapists can help their clients maintain their sense of hope in vocational recovery, gain better self-awareness and work with clients at various stages of recovery rather than waiting for full functional recovery. Further research is required to help identify specific factors that contribute to the success of employment integration amongst people with bipolar disorder.
Key words: psychiatric disability, mood disorder, vocational rehabilitation, bipolar disorders, employment performance
Introduction
Bipolar disorder (BD) or manic-depressive illness is a chronic major mental illness, which for the majority of patients follows a pattern of relapsing episodes of mania and depression interspersed with periods of normality (Goodwin and Jamison, 1990). A person in a manic phase typically experiences a sustained elated or irritable mood with a combination of the following features: increased activity, decreased need for sleep, inflated self-esteem, over-talkativeness, distractibility, racing thoughts, impaired judgement which may lead to social and sexual disinhibition, along with grandiosity of thinking and frank psychosis. In contrast, episodes of depression are characterized by a lowered or sad mood, accompanied by a cluster of neurovegetative symptoms that are opposite to those seen during mania: difficulty sleeping or sleeping too much, reduced energy, anhedonia, feelings of self-reproach, impaired concentration, psychomotor agitation or retardation, lowered appetite for food and preoccupation with suicide or death. The depressive phase can be equally disruptive for the individual given the symptoms of low energy and motivation, poor memory, and problems with attention and concentration. By definition (Diagnostic and Statistical Manual IV criteria) the mood disturbance must be severe enough to cause marked impairment in social activities, occupational functioning, and interpersonal relationships and/or require hospitalization to prevent harm to self (American Psychiatric Association, 1994).
On the whole, it is estimated that BD has a lifetime prevalence in the general population of the United States ranging from 1% to 1.6%, and from 0.3% to 1.5% worldwide (Hilty et al., 1999). For example, the lifetime prevalence was reported at 1% in New Zealand (Silverstone and Romans, 1995) and 0.97% in Iceland (Boyd and Weissman, 1982). The mean age of onset of BD is 21 years and the reported female:male ratio lies between 1.31 and 2:1 (Silverstone and Romans-Clarkson, 1989).
It has long been accepted that BD runs a chronic but remitting course, and has a relatively favourable outcome without major impact on psychological, social or vocational functioning (Winokur, 1975; Tsuang et al., 1979; Zis and Goodwin, 1979; Grof et al., 1995). Recent studies on the natural course of BD have, however, challenged this view by suggesting that BD has a significant adverse impact on individuals, in terms of their functioning in both daily activities and employment (Goldberg et al., 1996; Kusznir et al., 1996; Solomon et al., 1996; Stefos et al., 1996; Keck et al., 1998; Kessing, 1998). Among these studies, Keck and associates (1998) found that during a 12month follow-up post hospitalization, syndromal recovery occurred in 48% of the 134 patients with BD, symptomatic recovery occurred in only 26% and functional recovery in only 24%.
In the United States, the estimated costs from BD for 1991 totalled $45 billion. These costs were broken down into direct and indirect components, with direct costs totalling $7 billion (consisting of expenditures for inpatient and outpatient care), while indirect costs were estimated at $38 billion (including lost productivity of both wage-earners ($17 billion) and homemakers (3 billion)) (Hilty et al., 1999). Estimated lost cumulative days from work for 1990 amongst patients with BD in treatment in the USA were 152 million days while untreated patients lost another 137 million days (Hilty et al., 1999). Furthermore, it was found that on average there were a total of 25 work loss days per month per 100 workers with affective disorder (Kessler and Frank, 1997). At the individual level, the impact of BD without treatment is even more dramatic, with it being estimated that a woman experiencing the onset of her illness at age 25 years will lose approximately 9 years of life, 14 years of effective activity and 12 years of normal health (Silverstone and Romans, 1996).
It is indisputable that people with BD, in keeping with the rest of the population, wish to engage in meaningful work, preferably paid and appropriately supported (Miller and Miller, 1997; Krupa et al., 1998). It is also well documented in the occupational therapy literature that engagement in paid work is seen as a process for, and outcome of, psychosocial rehabilitation for people with mental health problems (Vostanis, 1990; Westmorland, 1996; Durham, 1997; Steward, 1997). What is less well understood, however, is how people with BD fare in their search for, and retention of, paid work. Additionally, how much is known about the employment rates for people with BD and what work-related issues must people with BD, and society at large, have to address? These questions are important ones for a society such as ours where personal well-being and self-esteem are largely determined by one's position within the paid workforce.
Employment rates amongst people with BD
Six longitudinal studies (Dion et al., 1988; Tohen et al., 1990; Fabian, 1992; Coryell et al., 1993; Gitlin et al., 1995; Goldberg et al., 1995) with follow-up periods ranging from 3 months to over 6 years have suggested employment rates among people with BD of between 27% and 72%. In contrast, four other studies (McPherson et al., 1992; Romans and McPherson, 1992; Kusznir et al., 1996; Tsai et al., 1997) using a cross-sectional data collection method found the rate of full-time employment to vary between 16% and 36%. Table 1 summarizes the various characteristics of the ten studies reviewed. One needs to interpret such findings with caution as a number of methodological shortcomings exist in most of the studies. For example, few studies clearly indicated whether or not employment was full- or part-time and clearly the type of methodological design had a significant effect on the results, with the crosssectional studies finding relatively lower employment rates than those found in the longitudinal studies. It is possible that a cross-sectional design does not allow researchers to investigate the improvements in psychosocial functioning that individuals need to make to return to work following an acute episode, yet which often lag behind symptomatic recovery. On the other hand, a crosssectional design may more accurately reflect the disruptive, intermittent effects of the illness on employment. Additionally, no attempt was made to measure personal satisfaction over employment and/or economic gains.
When employment rates for people with BD are compared to individuals with other severe psychiatric disorders, such as schizophrenia, people with BD appear to do better. For example, O'Neill and Bertollo (1998) reported a 63.6% employment rate among people with BD compared with 43.4% among people with schizophrenia. Overall, while rates of employment for people with BD appear better than those for people with other severe mental disorders, employment prospects remain rather limited.
Multiple reasons for this predicament have been put forward in the literature (Mowbray et al., 1997). Firstly, for a variety of reasons such as stigmatization, a failure of vocational services to respond to the particular needs of people with psychiatric disorders, as well as problems at policy-making and bureaucratic levels, people with psychiatric disabilities have less success in obtaining and maintaining a job. Secondly, the very nature of the disorder itself often leads to an interrupted work performance and gaps in an individual's work history, while the reduction in social network that results from unemployment will further reduce the likelihood of securing employment. Thirdly, many persons with severe mental illness experience their initial episodes of illness in adolescence or young adulthood, thus reducing opportunities for educational preparation and the acquisition of work skills, ethics and experiences that are essential for establishing a stable work record (Silverstone and Romans-Clarkson, 1989; Kessler et al., 1994). Finally, functional deficits associated with severe mental illness can create workplace problems such as inconsistent performance and interpersonal difficulties.
On the other hand, a number of more recent studies have explored how these problems may be improved. In one study ratings on employment performance by people with BD were shown to be improved by teaching patients to identify their early symptoms of relapse and to seek early treatment (Perry et al., 1999). Keeping lithium treatment optimal, as measured by serum levels, was shown in another study to improve employment performance (Solomon et al., 1996; Armond, 1998). Using a single case study design, factors identified as contributing to the successful outcome of vocational integration for one individual with BD including satisfaction gained from paid work, a sense of belonging to the organization where he was working, his sheer sense of determination to keep the job, a good previous work record and relief arrangements that were in place for when he was unwell (Tse et al., 1999).
Age of onset of illness and vocational functioning
While the age of onset of BD is well documented as occurring in a person's early adult life, little research has yet been carried out examining the relationship between the age of onset and successful vocational adaptation. Dion and associates (1988) reported the mean age at first hospitalization for people with BD as 25.8 years (SD 8.8 years), findings in keeping with those of other researchers who reported an average of 24 years (SD 9.5 years) (McPherson et al., 1992; Romans and McPherson, 1992). Similarly, Gitlin and associates (1995) noted a mean age of onset of 24 years.
In discussing the impact of an early onset of a psychiatric disorder like BD on an individual's occupational functioning, Simmons et al. (1993) pointed out that the onset of mental disorder in one's early twenties is likely to limit one's opportunities to complete vocational training and to develop a successful work ethic, for example, establishing appropriate attitudes and skills for work (Reker et al., 1992). When an individual has his or her onset of illness at an early age, it is also difficult for both the individual and his or her family to adjust, as grief over the loss of perceived current and future potential, both socially and occupationally, is particularly intense and draining at this point in a person's life cycle. In addition, the normal issues of adolescence and early adulthood such as personal identity, friendship and sexuality must be addressed even though mastery of each developmental milestone is made more difficult against a background of emotional instability. For many people, little energy is left to develop vocational maturity while they cope with the illness (Reker et al., 1992). Finally, a lack of vocational experience during adolescence and early adulthood may mean people with BD have difficulty in recognizing their own vocational interests, strengths and limitations (Glassner and Haldipur, 1985; King and Phillips, 1985). This difficulty may be further compounded by a distorted perception of self that often results from the cognitive changes accompanying the illness. In summary, while the young age of onset of BD is well documented, little is known about the relationship between age of onset and subsequent effects of the disorder on occupational functioning.
Psychiatric symptoms do not correlate with vocational performance
Several studies examining the relationship between vocational performance and symptomatology have suggested that a subgroup of individuals with BD continue to experience substantial psychosocial impairment during symptomfree periods. For example, in one study reporting employment rates amongst individuals with BD six-month post-hospitalization, employment rate was only 43% even though 80% of participants were symptom free or only mildly symptomatic (Dion et al., 1988). Similarly, another study by Kusznir and associates (1996) found one-third of participants had failed to achieve their optimal occupational performance despite being relatively euthymic in mood. It remains unclear, however, which specific factors lead to extended unemployment and psychosocial impairment amongst people with BD during these periods of apparent remission. Wiersma (1996) asserted that the course of symptomatology and social dysfunction may vary independently, noting that social disablement (e.g. unemployment, homelessness) in an individual is characterized more by social disability (e.g. lack of skills, lack of opportunities, negative societal attitudes) than by persistent psychiatric symptoms per se. In regard to employment, Anthony (1994a, 1994b) argued that dismissal from work was more commonly related to the disruption caused by multiple hospitalizations and poor work adjustment skills (related to getting along with people, job performance and reliability) than to psychiatric symptomatology (Anthony, 1994b).
Under-achieved vocational status
There is some evidence that the level of scholastic achievement attained at school by people with BD is higher than that of the general population (Coryell et al., 1993; Quackenbush et al., 1996). For example, in one study conducted in New Zealand, McPherson and associates (1992) found that people with BD were statistically more likely to have passed school certification than people from the local community. The long-term vocational status of people with BD, however, rarely appears to match their earlier scholastic achievement. Level of work satisfaction among people with BD is also low, with 31% of participants in one study regarding their job as uninteresting most of the time and 52% feeling their work was boring at least half of the time (Kusznir et al., 1996). Baron (1995) observed that people who recover from severe mental disorder and find their way into paid work are likely to end up working at unskilled jobs and in poorly paid positions. These findings, coupled with the unfulfilled high scholastic ability of people with BD, may, in part, explain their low level of work satisfaction. Unskilled jobs also tend to lack the flexibility people with BD require to meet their individual health needs - flexibility of hours and time off for illness. This in turn, will further limit the work choices of people with BD.
Showing improvement in the long term
One promising pattern in terms of employment amongst people with BD has emerged from several longitudinal studies (e.g. Tohen et al., 1990; Gitlin et al., 1995; Goldberg et al., 1995). A subgroup of people with BD appear to improve in their employment status four to five years after hospitalization (Tohen et al., 1990). Another study also showed increased work adjustment 4.6 years after hospital discharge when compared to ratings taken 2.1 years after discharge (Goldberg et al., 1995). Tohen and associates (1990) have suggested that these promising longer-term results (when compared to short-term follow-up study results) may more accurately reflect the individuals' true overall level of function. In short-term studies, researchers may still be studying the effects of the index illness which manifests itself as poor psychosocial functioning. An alternative explanation has been proposed by Goldberg and associates, who state that `many of these patients may benefit from their life experiences over time, developing more resilient and effective strategies for coping with recurrent illness' (1995: 383).
In summary, employment rates for people with BD are higher than those reported for people with other long-term mental disorders such as schizophrenia (e.g. Gitlin et al., 1995; Kusznir et al., 1996). Nevertheless, rates of employment amongst those with BD are low compared to the general population, especially in the first 2-3 years after hospitalization (McPherson et al., 1992). In addition, people with BD appear not to realize their early scholastic potential in terms of vocational achievements.
How occupational therapists can help people with BD find and retain employment
Occupational therapists will encounter people with BD who are at various stages of recovery from their mood disorder. Occupational therapists, because of their skills in evaluating individual skills and workplace supports that can affect a person's ability to work are in a unique position to help people. In particular, occupational therapists should focus on the following areas.
Fostering and helping people with BD maintain a sense of hope in regard to being able to work, especially over the longer term
It is vital to help individuals not to fall into the mentality of self-victimization as a result of having BD.
Vignette one (adapted from Health Funding Authority, 1999)
John was head boy at secondary school, a bright student who played rugby, was in the debating team and the Polynesian club and represented the school in athletics. Later, the pressure and stress of university examinations precipitated his first episode of mental illness and at the age of 19 John was diagnosed with bipolar disorder. Despite this diagnosis, he has not given up and is determined to fight against his mental illness and the subsequent discrimination of being denied educational and work opportunities. He is now a song-writer, owns his own recording studio and is very active in setting up psychiatric survivor networks to help others understand mental illness. John identifies several major steps on his pathway to vocational recovery, including a job looking after clients with intellectual handicap followed by occupational therapy. He also credits his recovery to having a supportive family, a hope or a strong belief that things would get better, and his love of music.
Helping clients increase their self-awareness
One of the major difficulties people with BD have in finding paid work is their lack of vocational maturity and self-awareness. Vocational maturity refers to one's development in the areas of attitudes towards work, work habits and having the social skills necessary to succeed in open employment. Self-- awareness has also been recognized as a key personal factor predicting success in employment (Anthony, 1994b) while Pollack (1995, 1996) found that recovery from BD was helped by a person's drive towards gaining a better understanding and awareness of one's self and the disorder.
With regard to work, self-awareness would encompass aspects of knowing one's own abilities, potential capacities, goals, values and ambitions, as well as one's limitations and early warning signals of relapse. Exploration of these topics is particularly relevant for individuals who have developed their illness at an early age, and for those individuals who have not yet developed a clear work identity because of the impact of the illness, or through a distorted selfperception and a chronically fluctuating mood. Lloyd and Bassett (1997) reported on a pre-employment programme for young people with psychosis situated in New South Wales, Australia. This programme has two main features. Firstly, the training in work skills and habits is implemented in real work situations and community environments. For example, the programme gained access to one of the local council properties, and participants were involved in refurbishing this building. This is a very effective way to help participants generalize their skills learnt in a therapy situation to real everyday situations and it can ease participants' transition to the real workplace (Hayes and Halford, 1992; Mueser et al., 1997). Secondly, in addition to training in work skills and habits, the programme emphasizes the development of self-awareness. These characteristics are enhanced through a number of group activities designed to be low-key, non-threatening and fun, incorporating client participation. Preemployment programmes such as this one in New South Wales may well provide a model upon which similar programmes aimed at people with BD can be developed in order to prepare them for training and competitive employment.
In order to help individuals develop their self-awareness, it is important to work with individuals to help them trace the pattern of their illness and to identify and reinforce coping mechanisms that work for them. People with BD will feel more able to work in partnership with a therapist if they feel understood, are treated with respect, and have their concerns taken seriously, for example, the adverse side effects of medication and its impacts on their workability.
Vignette two (the following two scenarios are provided by the first author)
Susan is in her mid-20s and has just recovered from her second episode of BD, which was characterized by a psychotic illness followed by severe depression. She no longer experiences any clinical symptoms but continues to lack energy, confidence, interest, concentration, and has very little hope for her own future work. Furthermore, Susan presents at a low level of vocational maturity due to the early onset of her illness (aged 16 years) and has no idea of how to go about finding a job. Her dream is to work in the arts and crafts and jewellery design industry. When working with Susan, a therapist should not prematurely conclude that Susan is not ready for work rehabilitation, or she may become discouraged and never pursue her ambitions. Instead, further exploration of her interests and abilities, and a careful activity analysis, will lead the therapist to being able to support Susan in coming to occupational therapy for an hour a day to do leather work to patch up her jeans and to begin to build her confidence. In this scenario, engagement in an activity is used as a vehicle by which rapport with the client can occur as well as providing her with an opportunity to gain feedback on her work performance, explore her interests and set graduated, achievable goals for herself.
In contrast, Mac who is in his early-40s, has outstanding qualifications and has accumulated an impressive work record over the past twenty years. Initially he is extremely optimistic about finding competitive employment but his job searching is hampered by his need to find a job that will accommodate his need for five to seven short breaks during the day because of generalized tiredness, while still being meaningful to him. Based on previous experiences of returning to work after similar episodes, Mac and his occupational therapist agree Mac will not benefit from hospital-based work training, but rather that Mac should look immediately for supported employment opportunities (Anthony and Blanch, 1987). In particular, Mac should look for placements that match his work experience and qualifications but will allow a heightened level of-support to be put in place. Doing an entry-level job in order to ease Mac back into the workforce is likely to lead quickly to demoralization and boredom. To maintain Mac's long-term wellness, a cognitive behavioural treatment approach is used to help educate him about BD and its treatment, to promote adherence to treatment, strengthen his abilities to cope with psychosocial stresses, boost self-confidence and esteem, and monitor recurrence of his symptoms (Solomon et al., 1995; Hilty et al., 1999).
Providing long-term and credible supports within the workplace for people with BD in view of the episodic nature of the illness
West and Parent (1995) suggest that community and workplace supports for individuals with mental disorders should relate to a variety of issues such as finding suitable accommodation, getting transportation to and from work, needing prompts on how to do the work, occupational health and safety issues and promoting social interaction with workmates at the workplace. Using a sociological model, Blankertz and Keller (1997) developed a comprehensive framework outlining four types of long-term support required: intrapersonal, interpersonal, social networks and work supports. Intrapersonal supports refer to developing those general skills necessary for an individual to function effectively in daily work situations; for example, providing positive feedback to help individuals develop a positive self-image and improve their self-confidence. Interpersonal supports refer to helping individuals establish one-onone relationships such as with their co-workers, in which they meet the needs of others as well as having their own needs met. Social networks can be composed of the natural supports of family, or whanau (meaning extended family for Maori, indigenous people in New Zealand), individuals who are also recovering from psychiatric disability, or co-workers in the workplace. Such networks help by providing support to the individuals by belonging to a small group. Work supports include those specific job-related skills, as well as workplace supports and accommodation, that an individual may need to acquire or maintain work. Based on preliminary data, Blankertz and Keller (1997) asserted that intrapersonal issues must be dealt with first, followed by interpersonal and finally, work-related issues.
Being creative in finding paid employment or work-related experiences for clients
Generally speaking, people with BD achieve well academically during their adolescent years (McPherson et al., 1992). They may not, therefore, be prepared to confine themselves to entry-level jobs just because they have developed an illness. In order to assist clients with BD achieve their vocational goals, occupational therapists must become more actively involved in supported education (Dougherty et al., 1996; Weiner, 1996), in ensuring better collaboration with employers (Westmorland, 1996) and consumers (Krupa, 1998) in order to create more work-related options for people with BD. For example, in the context of providing vocational rehabilitation for people under the forensic psychiatric services in the United Kingdom, Garner (1995) advocated the use of vocational programmes that could be cross-credited to existing national educational structures or frameworks. This would certainly help participants in this kind of programme advance to higher levels of educational and/or training opportunities. Furthermore, it is important for both the clients and therapists to adopt an attitude that clients may need to try several jobs before they find one they like and one that gives them a good career prospect and/or helps maintain their wellness (Baron and Salzer, 2000).
As the majority of us who work as occupational therapists are employees working in health or human service sectors, it is possible that we are confined by our limited experience in regard to the breadth of employment options available. In contrast, Tryssenaar (1998) described a whole range of work options, including volunteer work, sheltered work, cooperatives, affirmative business, home-based employment, transitional employment, supported employment, casual employment, self-employment, part-time and full time competitive employment, that are available for individuals recovering from mental illness.
Clearly there is an urgent need for future research to be carried out in this field, to delineate further those factors that contribute to the employment success or otherwise of people with BD. For example, it will be important to identify those specific factors that help, or actively hinder, people with BD gaining open employment. Are factors such as the subtype (I or II - recurrent major depression with hypomania) of BD, an individual's level of insight or self-- determinism, available social supports, treatment compliance, illness acceptance and/or disruption to work important in predicting who will return to or remain at work? What kind of pre-employment and ongoing workplace supports are helpful for people with BD in finding and keeping employment? Naturalistic, in-depth and long-term longitudinal research on work rehabilitation for people with BD will be important if we are to develop an understanding of the various stages of work adjustment and the impact this disorder has on one's career.
A major limitation of the present review is that the authors have only considered paid work. This limitation undermines the fact that some people with BD make a conscious decision not to join the workforce for social reasons such as looking after a family member at home, or in order to avoid too much stress to enhance their chance of remaining well (Scheid and Anderson, 1995). As Martin (1996: 278) stated, '(for some individuals) the best way of avoiding relapse was to stay out of stressful situations such as paid employment'. In view of this, many prefer to engage in other forms of occupation such as voluntary work in the community, and creative art work (Oxley, 1995; Kusznir et al., 1996). Others choose to stay away from paid work because taking on paid employment will mean the loss of their entitlement for income support upon which they depend for their livelihood.
Conclusion
For people with BD to be successful in the workforce, several issues must be addressed. At a societal level, major attitudinal changes on the part of healthcare workers and potential employers are needed in order to foster the belief that people with mental illness can find, and retain, open employment. Despite the current problems, some individuals with BD continue to achieve extremely well in their own field of professional practice such as tertiary education, information technology, commerce and health. At an individual level, issues such as the effective management of the illness, the development of appropriate coping strategies to deal with the stresses of the workplace, the development of work skills and aptitude, and the accurate self-appraisal of one's abilities and limitations will all be important. Patients with BD are often highly valued workers (Romans and Silverstone, 1994) bringing energy, drive, creativity and a sense of optimism and positivity to the workplace. Their lateral thinking is also helpful in difficult situations at work. Changes at the legislative level (e.g. the implementation of Americans with Disabilities Act 1990 in United States, the Human Rights Act 1993 in New Zealand) will be paramount in preventing discrimination against, and in promoting the accommodation of, people with psychiatric disability in the workplace. Such legislative changes may also increase training and employment options for people with psychiatric illness, by allowing jobs to be matched more closely to an individual's skills and values, as well as to their limitations. For people with BD, such flexibility may well ensure their ability to secure employment that is suited to their academic abilities and removes the need for them to accept unrewarding, entry-level jobs. As with all workers, it will be important that the appropriate supports are in place so that individuals with BD can ease into the work role. In particular, support will be required from family, friends, coworkers and employers at the workplace. Undoubtedly these issues present an on-going challenge for people with BD and their families, and for all health professionals including occupational therapists.
Acknowledgement
Funding support for the preparation of this manuscript was provided by the Otago Polytechnic, Research and Development Fund (Dr Tse) and University of Otago, Bequest Fund (Dr Walsh).
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SAMSON S. TSE School of Occupational Therapy, Otago Polytechnic, Dunedin, New Zealand
ANNE E. S. WALSH Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, New Zealand
Address correspondence to Samson Tse, Department of Occupational Therapy, Otago Polytechnic, Private Bag 1910, Dunedin, New Zealand. Email: [email protected].
Copyright Whurr Publishers Ltd. 2001