State of the Art

There was a time when there were no effective treatments for psychiatric disorders, and patients were locked in asylums. After the introduction of effective psychopharmacologic treatments, patients were discharged, and achieving symptomatic improvement was the goal. Later on, we learned that improvement was not enough, and remission became the new paradigm. The combination of pharmacotherapy and psychotherapy was aimed at that objective. Nowadays, we have become aware that even remission is not the right objective, because many patients suffer from psychosocial and functional impairment despite the absence of symptoms of the disease. This is particularly true for bipolar disorders. Thus, recovery (meaning functional recovery) is the actual goal in this condition. Hence, a number of studies have analyzed the risk factors involved in poor functional outcome in bipolar disorder. Moreover, a few more studies have focused on resilience and protective factors. Finally, the most recent clinical trials on pharmacological and psychosocial treatments have progressively introduced functional outcomes as key endpoints, yielding useful information on how to enhance the chance of functional success. Clinical factors such as male gender, older age, lower premorbid IQ, subdepressive symptoms, higher number of manic episodes and lower performance in verbal memory, working memory, verbal fluency and processing speed have been reported as associated with lower functioning in patients with bipolar disorder. Genetic and neuroimaging findings have also increased our knowledge on this matter. Novel treatments, such as functional remediation techniques, hold promise in combination with innovative pharmacotherapy and brain stimulation techniques.