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Functional impairment in adolescents and young adults with emerging mood disorders

  • Jan Scott (a1), Elizabeth M. Scott (a2), Daniel F. Hermens (a3), Sharon L. Naismith (a3), Adam J. Guastella (a3), Django White (a3), Bradley Whitwell (a3), Jim Lagopoulos (a3) and Ian B. Hickie (a3)...



Between 30 and 60% of adults with unipolar or bipolar disorders exhibit impairments across multiple domains. However, little is known about impaired functioning in youth with mood disorders.


To examine the prevalence of objective, subjective and observer-rated disability in a large, representative sample of young people with a primary mood disorder.


Individuals aged 16–25 years presenting to youth mental health services for the first time with a primary mood disorder participated in a systematic diagnostic and clinical assessment. Impairment was assessed using objective (unemployment or disability payments), observer- (Social and Occupational Functioning Assessment Scale; SOFAS) and self-rated measures (role functioning according to the Brief Disability Questionnaire).


Of 1241 participants (83% unipolar; 56% female), at least 30% were functionally impaired on the objective, self-rated and/or observer-rated measures, with 16% impaired according to all three criteria. Even when current distress levels were taken into account, daily use of cannabis and/or nicotine were significantly associated with impairment, with odds ratios (OR) ranging from about 1.5 to 3.0. Comorbid anxiety disorders were related to lower SOFAS scores (OR = 2–5).


Levels of disability were significant, even in those presenting for mental healthcare for the first time. Functional impairment did not differ between unipolar and bipolar cases, but some evidence suggested that females with bipolar disorder were particularly disabled. The prevalence of comorbid disorders (50%) and polysubstance use (28%) and their association with disability indicate that more meaningful indicators of mood episode outcomes should focus on functional rather than symptom-specific measures. The association between functioning and nicotine use requires further exploration.

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Corresponding author

Jan Scott, Newcastle University, Academic Psychiatry, Newcastle General Hospital, Westgate Road, Newcastle NE4 6BE, UK. Email:


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Declaration of interest

I.B.H. has led projects for health professionals and the community supported by governmental, community agency and pharmaceutical industry partners (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) for the identification and management of depression and anxiety. He has received honoraria for educational seminars supported by the pharmaceutical industry (including Pfizer, Servier and Astra Zeneca). He has served on advisory boards convened by the pharmaceutical industry (including Bristol-Myers Squibb, Eli Lilly and Pfizer) in relation to specific antidepressants. His research has been supported in part by pharmaceutical manufacturers (including Servier and Pfizer). D.F.H. has received honoraria for educational seminars from Janssen-Cilag. E.M.S. has received honoraria for educational seminars related to the clinical management of depressive disorders supported by Servier and Eli Lilly. She has participated in an advisory board for Pfizer. J.S.'s research has been supported by funds provided to the NTW NHS Trust by Astra-Zeneca and Janssen-Cilag for investigator-initiated studies on medication adherence. She has received honoraria for educational seminars supported by the pharmaceutical industry and has served on advisory boards convened by the pharmaceutical industry (including Astra-Zeneca, Janssen-Cilag, Lundbeck, Pfizer, Sanofi-Aventis and Servier).



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Functional impairment in adolescents and young adults with emerging mood disorders

  • Jan Scott (a1), Elizabeth M. Scott (a2), Daniel F. Hermens (a3), Sharon L. Naismith (a3), Adam J. Guastella (a3), Django White (a3), Bradley Whitwell (a3), Jim Lagopoulos (a3) and Ian B. Hickie (a3)...
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Rahul S. Bharadwaj, Consultant Psychiatrist and Conjoint Senior Lecturer
19 December 2014

Scott et al with their paper Functional impairment in adolescents andyoung adults with emerging mood disorders make a valuable contribution to the area of youth mood disorder research. I would like to raise a few points.

Given that this study was conducted in Australia, it would be interesting to know what percentage of the participants identified as Aboriginal and Torres Strait Islander (ATSI) peoples. Aboriginal and Torres Strait Islander peoples generally have poorer health, are more likely to experience disability and reduced quality of life. For Indigenous young people, this burden is largely attributable to the high rates of mental disorders, such as anxiety and depression, substance use, and injuries. As an example, 33% of Indigenous of young people aged 18-24 years were rated as having high or very high levels of psychological distress as measured by the Kessler 5 (K5) scale (2007-08) as compared to 14% of non- Indigenous youth, with this difference being statistically significant. The factors that contribute to this health inequality are complex, and include cultural, historical, environmental and socioeconomicelements (1, 2).

In this study, disability was defined as receipt of financial support(yes/no). In Australia, 16-25 year olds can qualify for various types of financial support: the Youth Allowance if they are studying, training, looking for work or sick; the Newstart allowance if they are aged 22 yearsor more (but under Age Pension age), looking for paid work and prepared tomeet the activity test while they are looking for work; the Disability support pension if they are aged between 16 years of age and Age Pension age, have been assessed as having a physical, intellectual, or psychiatricimpairment and are unable to work, or to be retrained for work. As is evident, these financial assistance packages support youth with various degrees and types of disability. It is likely, therefore that psychiatric disability was over-estimated by this measure (3).

The study used the K-10 questionnaire to measure perceived distress and the Social and Occupational Functioning Assessment Scale (SOFAS) to objectively assess functioning. The K10 questionnaire is a useful but non-specific measure of psychosocial distress, used frequently as a screening instrument (4). The use of an instrument (a rating scale like Hamilton Depression Rating Scale for example for those meeting criteria for major depressive disorder) (5) that could capture specific information on the symptomatology of the mood disorder and its severity would have been valuable, particularly since only individuals with established mood disorders and currently meeting syndromal criteria were included. With regards to the SOFAS, it is important to remember that the SOFAS tends to confound functioning with symptomatology (6) and according to some authors, it is a general measure of illness severity rather than functioning (7). Furthermore, future studies are likely to benefit from the use of multidimensional scales (unlike global scales like the SOFAS) to measure functional impairment and adaptive functioning which have been developed to more accurately assess 'functioning' in youth (7).


1.Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHW.2.Australian Bureau of Statistics 2014, Information Paper: Use of the Kessler Psychological Distress Scale in ABS Health Surveys, Australia, 2007-08, viewed 8 December 2014, Government, Department of Human Services 2014, viewed 9 December 2014,, G. & Slade, T. Interpreting scores on the Kessler Psychological Distress Scale (K10), Australian and New Zealand Journal of Public Health, 2001, Vol 25(6), 494-75.Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23:56-626.Winters NC, Collett BR and Myers KM. Ten-Year Review of Rating Scales, VII: Scales Assessing Functional Impairment. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(4):309-3387.Smith GN, Ehmann TS, Flynn SW, et al. The assessment of symptom severity and functional impairment with DSM-IV Axis V. Psychiatric Services 2011; 62:411-417

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