Cognitive deficits, depression and education level all predict worklessness in bipolar disorder, says systematic review


People with bipolar disorder have high levels of post 16 years education, but it’s estimated that only half of those living in Europe with the condition are in paid employment. This is a real concern because the illness typically affects young and middle-aged people who would normally be active in the workforce.

Of course, living with a severe mental illness like bipolar disorder can be extremely challenging and it’s not always possible to get on with regular routines when episodes of depression or mania strike.

However, policy-makers and commissioners should take note of the fact that the healthcare costs for mental health disorders are only half of the costs of the productivity lost to worklessness from those same conditions (Patel and Knapp). Surely more investment in mental healthcare is a no brainer in these times of austerity?

[Readers interested in reading more about the family and societal costs of mental health should check out the excellent work of Martin Knapp – there are some links at the end of this blog].

Eleanor Gilbert and Steven Marwaha from the University of Warwick have published a systematic review of the predictors of employment in bipolar disorder. They hope that a better understanding of these predictors will help us reduce the about of time lost to worklessness in this population each year.

The authors conducted a decent search and, following a systematic process of sifting and appraising, included 9 studies in their review (including a total of 3,184 patients). The included studies had the following characteristics:

  • Patients with bipolar disorder I or II or the sample was described as having a severe mental illness (irrespective of whether early or established cases of bipolar disorder were sampled)
  • Therapy trials with a ‘treatment as usual’ control arm
  • Prospective samples (of at least 15 people)
  • Follow-up of at least 6 months

The authors had planned to carry out a formal meta-regression analysis, but were unable to do this as the included studies used different measures of employment and work functioning and so could not be pooled in this way. Overall the small number of studies mean that the findings of this review are subject to change.

Here’s what they found:

  • The following predictors of employment in bipolar disorder patients were identified:
    • Cognitive deficits (67%, n=4)
    • Depression (43%, n=3)
    • Level of education (33%, n=2)
  • Bipolar depression affects employment status and time off work
  • Subsyndromal (minor) depression also damages employment prospects
  • Verbal memory and executive functioning appear to be predictors of work functioning

The reviewers concluded:

Better assessment and management of depression and cognitive difficulties could improve the occupational functioning of bipolar disorder patients. There is a need for high quality longitudinal studies specifically designed to investigate predictors of employment in large bipolar disorder samples.


Gilbert E, Marwaha S. Predictors of employment in bipolar disorder: A systematic review. Journal of Affective Disorders, 2012.

Patel A, Knapp M. Costs of mental illness in England. Mental Health Services Research Review 1998;5:4-10.

Knapp M, McDaid D, Parsonage, M. Mental Health Promotion and Mental Illness Prevention: The Economic Case (PDF). Department of Health, 14 Apr 2011.

Knapp, M. Mental Capital and Wellbeing: Making the most of ourselves in the 21st century (PDF). State-of-Science Review: SR-B8 Mental Ill-health: Cost Implications, 2008.

Knapp, M. Mental health in an age of austerity. Evid Based Mental Health 2012;15:54-55 doi:10.1136/ebmental-2012-100758.

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Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland!

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