Work motivation in patients with bipolar disorder: Associated factors

Abstract

Background:

Occupational functioning is severely impaired in patients with bipolar disorder (BD). Work motivation (WM), defined as the psychological processes that determine the direction, intensity, and persistence of action within the work, is an essential component of work-related functioning.

Aim:

To assess whether WM is affected in patients with BD and which clinical and sociodemographic factors are related to low WM.

Methods:

In all, 95 euthymic BD patients were invited to answer the Motivation for Work Questionnaire and the Rating Scale on Subjective Cognitive Deficits in Bipolar Disorder (COBRA).

Results:

A total of 49.5% (n = 47) of the patients were classified in the Low Motivated (LM) group. Unemployment and the report of more subjective cognitive complaints were predictors of poor WM in this sample ((OR) = 3.01 and 7.10, respectively).

Conclusions:

Perceived cognitive deficits related to the disorder and current unemployment negatively impact WM in patients with BD. In addition to symptomatic recovery, the need of the inclusion of personal and occupational areas in the comprehensive treatment of patients with BD is necessary.

Keywords

Cognition employment bipolar disorder job satisfaction motivation rehabilitation severe mental illness

Introduction

Bipolar disorder (BD) is a chronic condition affecting mood regulation. Over 48.8 million people worldwide struggle with this gravely disabling condition (Ferrari et al., 2016; Merikangas et al., 2012).

Occupational functioning, in particular, is severely impaired in this population: people with BD have greater unemployment rates, lower work motivation (WM), more absenteeism at work and poorer work-related outcomes than those without a mental condition (Gitlin & Miklowitz, 2017). Occupational dysfunction generates substantial burden to individuals and society (Baune & Malhi, 2015; Gilbert & Marwaha, 2013; Grande et al., 2013). Examples of clinical characteristics affecting occupational functioning in BD are depressive symptoms, number of manic episodes and recent admissions (Gutiérrez-Rojas, Jurado, & Gurpegui, 2011; Tse, Chan, Ng, & Yatham, 2014). Cognition, when objectively measured, is severely impaired in BD (Miskowiak et al., 2018) and has also been associated with occupational outcomes: flaws in attention, verbal memory, executive functions and processing speed have been found to be related to low employment (Bearden, Woogen, & Glahn, 2010; Levy & Manove, 2012). Subjective cognitive complaints have also been found to be highly prevalent in this population (Rosa et al., 2013; Yoldi-Negrete et al., 2018). Cognitive complaints have been associated with perceived difficulties in managing work tasks and withdrawal from occupational activities (Baker, Gibson, Georgiou-Karistianis, & Giummarra, 2018; Stenfors, Magnusson Hanson, Oxenstierna, Theorell, & Nilsson, 2013). Also, other individual factors such as being single and lower education are environmental factors that negatively impact occupational functioning (Grande et al., 2013; López Menéndez, 2008).

WM is defined as the psychological processes that determine the direction, intensity and persistence of action within the work (Kenfer, 1990), as such, it is an essential component of work-related functioning. Motivation is determined by the combination of individual and environmental characteristics (Kanfer, Chen, & Pritchard, 2008). Individual characteristics refer to the worker’s capabilities (emotional and cognitive), needs and expectations, while environmental characteristics refer to job content, work load, organizational conditions and social support (Singh-Manou, 2003). To our knowledge, the extent to which WM is affected in patients with BD and the factors that impact it negatively have not been studied. Therefore, the aim of this study was to assess whether WM is affected in patients with BD and which clinical and sociodemographic factors are related to low WM.

Methods

The study was carried out at the National Institute of Psychiatry Ramón de la Fuente Muñiz (INPRFM) in Mexico City, which is a highly specialized mental health center in Mexico City. The Ethics and Scientific Committees of the INPRFM approved the study procedures and all participants gave their written consent.

Subjects

Outpatients with BD type I according to the Diagnostic and statistical manual of mental disorders (5th ed.; DSM-5) (American Psychiatric Association, 2013) criteria were recruited from April 2017 to October 2017 from the Affective Disorders’ Clinic at the INPRFM. Patients were included if they were between 18 and 65 years old and had been euthymic for at least 1 month according to medical records. The interview conducted in this clinic is semi-structured and follows DSM-5 mood episode criteria. Patients were excluded if they had neurological comorbidities or medical comorbidities which could explain either cognitive complaints or low WM. Permitted psychiatric comorbidities included generalized anxiety disorder, panic disorder and substance use disorder in remission, according to DSM-5 criteria (no substance use in the past year).

Instruments

Rating scale on subjective cognitive complaints in bipolar disorder

The rating scale on subjective cognitive complaints in bipolar disorder (COBRA) is a self-administrated questionnaire that evaluates subjective cognitive complaints including executive function, processing speed, memory, attention and concentration. It consists of 16 items rated on a 4-point Likert-type scale (from 0 = Never to 3 = Always). Higher scores refer to more subjective complaints, and the proposed cut-off point is 10 (Rosa et al., 2013). This instrument has been validated in Mexican population (Yoldi-Negrete et al., 2018).

Motivation for Work Questionnaire

This is a self-administered instrument designed by Colis and colleagues (Colis & Galilea, 1995) which evaluates the attitude of a person with a severe mental disorder to participate in work activities. It consists of 37 true/false items, each item is rated according to an established answer sheet, and a total score from 0 to 100 is obtained. Higher scores mean that patients are more motivated to work. The questionnaire was designed and validated in Spanish population (Pascual, Lopez, & Coy, 1998).

Procedure

Participants were asked to answer the Motivation for Work Questionnaire (MWQ) and the COBRA scale. Clinical data (age at illness onset, predominant polarity, number of affective episodes, number of hospitalizations, presence of psychotic symptoms, psychiatric comorbidities and time in euthymia) and sociodemographic data (gender, age, years of education, marital status, occupational status and economical support from their family) were obtained from medical records.

Statistical analysis

All statistical procedures were performed using the Statistical Package for the Social Sciences (SPSS), version 21. Frequencies and percentages were calculated for categorical variables and means and standard deviation (SD) for continuous variables. Sample was divided into Low Motivated (LM) and Highly Motivated (HM) according to the median score of the MWQ, and demographic and clinical variables were compared with chi-square tests (χ²) for categorical variables and independent sample t tests for contrasts of continuous variables. Variables with significant differences in the comparative analyses were considered as potential predictors and an association analysis with the MWQ was performed with Pearson correlation coefficients. Those variables with significant correlations were included in multivariate logistic regression analyses as explanatory variables and low motivation as the outcome variable. Significance level for all tests was established at p < .05 (two-tailed).

Results

A total of 95 patients with a mean age of 39.1 years (SD 11.7 years, range: 20–65 years) were included. Most of the patients were women (67.4%, n = 64), single (62.1%, n = 59) and employed (73.7%, n = 70) with an average of 14.6 years of education (SD = 3.4 years, range: 4–23 years). 64.2% (n = 61) received economical support from their relatives.

Mean age of illness onset was 25.5 years (SD = 9.4 years, range: 14–58 years) with an average of 4.8 (SD = 2.4 years, range: 1–14 years) episodes during illness evolution. Mean time of euthymia before the inclusion of patients in the study was 28.0 months (SD = 34.5 months). Predominant polarity was undetermined for more than half of the patients (53.7%, n = 51), while for 25.3% (n = 24) polarity was manic and for the remaining 21.1% (n = 20) it was established as depressive. Comorbidity was reported only in 11.6% (n = 11) of the patients, mainly anxiety disorders (81.8%, n = 9 from those with comorbidity). Most of the patients (90.5%, n = 86) had a history of psychiatric hospitalizations with a mean of two hospitalizations (SD = 1.4, range: 1–7) and reported psychotic symptoms (89.5%, n = 85) at some point during illness evolution.

At the time of the study, the mean score of the COBRA scale was 14.0 (SD = 7.9, range: 0–34), and according to the proposed cut-off point of the scale (10 points), 65.3% (n = 62) of the patients had significant subjective cognitive complaints. The mean score of the MWQ was 75.3 (SD = 12.8, range: 37.8–98.3), and using the median (81.0 total score), 50.5% (n = 48) of the patients were classified in the HM group and 49.5% (n = 47) in the LM group. In the LM group, 87.2% (n = 41) had significant cognitive complaints and in the HM group 43.8% (n = 21) had significant cognitive complaints based on the cut-off point of 10 of the COBRA score (Rosa et al., 2013). The comparisons between motivation groups are displayed in Table 1.

Table 1.

Comparison of demographic and clinical characteristics according to motivation status.

	Low Motivated (n = 47)		Highly Motivated (n = 48)		Statistic
	n (%)		n (%)		Statistic
Gender: women	35	74.5	29	60.4	χ² = 2.1, p = .14
Unmarried	33	70.2	26	54.2	χ² = 2.5, p = .10
Occupation: unemployed	18	38.3	7	14.6	χ² = 6.8, p = .009
Economical support: yes	34	72.3	27	56.3	χ² = 2.6, p = .10
Comorbidity: yes	5	10.6	6	12.5	χ² = 0.08, p = .77
Polarity
Undetermined	24	51.1	27	56.3
Manic	13	27.7	7	14.6	χ² = 2.6, p = .26
Depressive	10	21.3	14	29.2
Psychiatric hospitalization: yes	43	91.5	43	89.6	χ² = 0.1, p = .75
Presence of psychotic symptoms	44	91.4	41	87.2	χ² = 0.4, p = .48
Cognitive complaints: yes^a	41	87.2	21	43.8	χ² = 19.8, p < .001
	Mean (SD)		Mean (SD)
Current age (years)	38.7	12.1	39.4	1.4	t = −0.2, p = .77
Years of education	14.3	3.9	15	2.8	t = −0.8, p = .37
Age of illness onset (years)	24.8	9.1	26.2	9.7	t = −0.7, p = .46
Psychiatric hospitalizations (number)	2.1	1.5	2	1.4	t = 0.2, p = .82
Clinical episodes (number)	5.1	2.7	4.6	2.1	t = 0.8, p = .38
Euthymia: months	19.7	20.1	36.2	3	t = −2.3, p = .01
COBRA score	18.3	7.7	9.7	5.4	t = 6.2, p < .001

COBRA: Rating Scale on Subjective Cognitive Deficits in Bipolar Disorder.

Based on the cut-off point of 10 of the COBRA score.

As can be seen, both groups were similar in most of the demographic and clinical characteristics. A higher number of patients in the LM group were unemployed, had fewer months in euthymia and reported higher scores on the COBRA scale, indicative of more subjective cognitive complaints.

Employment, months in euthymia and COBRA scale were the main potential predictors of low motivation to work. These variables showed significant correlations with the MWQ across the sample (employment r = −.21, p = .03; months in euthymia r = .27, p = .006; COBRA scale r = −.51, p < .001) and were included in the logistic regression analysis. The results of the regression model are shown in Table 2 where the most important predictors of low motivation to work were unemployment and the presence of subjective cognitive complaints. Fewer months in euthymia did not reach significance in the prediction of low motivation in BD patients.

Table 2.

Logistic regression model for the prediction of low motivation to work in BD patients.

	β	Odds ratio	95% CI	p
Employment: no	1.19	3.29	1.001–10.94	.05
Months in euthymia	−0.10	0.99	0.97–1.008	.268
COBRA score	0.19	1.20	1.10–1.31	<.001

BD: bipolar disorder; CI: confidence interval; COBRA: Rating Scale on Subjective Cognitive Deficits in Bipolar Disorder.

Discussion

The aim of this study was to assess whether WM is affected in patients with BD and which clinical and sociodemographic factors are related to it. We found that subjective cognitive complaints and unemployment were the only predictors of low work motivation (LWM). The risk of having LWM is increased by 1.2-folds for every one point increase in COBRA score and 3-fold if they were unemployed. Time in euthymia was found to be a protector against LWM.

In Mexico, the unemployment rate is about 3.5%, which is lower than other unemployment rates in Latin America and even lower than some high-income countries (Forbes México, 2013). However, 56.6% of the working population has an informal employment (National Institute of Statistics and Geography, 2013), which means no social security and unstable income for the employee. Finding and maintaining a secure position in Mexico is difficult even among people unaffected by mental illness as even formal employment offers little security to employees: contracts for short periods of time (up to 12 months) with no social-security benefits are common, resulting in constant cycling between employment and unemployment and increase in stress and uncertainty (Contador Mex, 2013; National Council for Science and Technology, 2017). Therefore, people with BD face an even greater challenge given mental health stigma and the scarcity of work opportunities (Ellison, Mason, & Scior, 2013; Grover, Hazari, Aneja, Chakrabarti, & Avasthi, 2016). Given these unfavorable working conditions, the employment status, which is commonly understood as an outcome of being motivated, was explored as a potential factor affecting WM. Unemployment could be seen as both a cause and a consequence of low WM: unemployment might only be reflecting the poor WM, but the inability to find and/or maintain a job fulfilling the patient’s expectations could be affecting motivation to pursue the quest, becoming a vicious circle.

In this study, neither the number of episodes nor the number of hospitalizations or history of psychosis was related to WM implying a greater importance of cognitive factors than illness evolution. We hypothesize that if patients perceive flaws in executive function, processing speed, memory, attention and concentration, they might feel inadequate for occupational activities, reflected in a low WM and high rates of unemployment despite a high level of education (when compared to the general population¹) and prolonged euthymia. This is coincidental with other studies showing the importance of cognitive functioning in daily life (Baune & Malhi, 2015; Levy & Manove, 2012; Martino et al., 2009; Mur, Portella, Martinez-Aran, Pifarre, & Vieta, 2009).

In any psychiatric condition, the first step to improve work functioning in rehabilitation programs, is to ensure a symptomatic remission (Martino et al., 2009) and to explore patients’ abilities, capabilities and WM (Hilarion & Koatz, 2012). Our results show that in BD, remission is not enough; cognitive complaints should also be considered.

Some limitations of this study should be mentioned. First, the cross-sectional nature of the study limits the generalization of our results in terms of illness evolution and prognosis. Future longitudinal studies should be performed to determine how changes in the subjective cognitive deficits may relate to changes in WM and even in the performance of work. Also, an additional objective cognitive evaluation should be included as subjective and objective evaluations do not always concur (Miskowiak et al., 2016) and subjective perception may reflect other situations more related to individual differences (i.e. personality features, self-esteem, empowerment; Lloyd, King, & Moore, 2010). Moreover, other environmental and cultural factors related to Mexican society and work should be assessed in order to have a wider vision of WM as a multifactorial construct.

Despite the above limitations, this study emphasizes the need of the inclusion of subjective experiences and occupational areas in the comprehensive treatment of patients with BD. Symptomatic remission is important; however, overcoming the barriers our patients face in order to reintegrate into a daily functioning within society should be our greatest work as mental health professionals.

Footnotes

Acknowledgements

We would like to thank Lizeth González Pantoja for her help in the recruitment of participants.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

ORCID iDs

Sara Martínez-Camarillo

María Yoldi-Negrete

Ana Fresán-Orellana

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