Affective disorders (bipolar disorder (BD) and unipolar depressive disorder (UD)) are associated with functional impairment, not only during affective episodes but also during periods of remission (Léda-Rêgo et al., 2020; Sheehan et al., 2017). Impairment is often present in several areas of functioning such as occupational functioning and social functioning, as well as impairment in overall/global functioning (Léda-Rêgo et al., 2020; Chen et al., 2019). As described in The International Classification of Functioning, Disability and Health (ICF), functional impairment is multicausal, resulting from a complex interplay of different factors such as health conditions, environmental factors and personal factors (WHO 2001).

We currently lack a comprehensive understanding of key factors causing and sustaining functional impairment in patients with affective disorders. Several clinical factors are associated with functional impairment, such as affective symptoms, number of affective episodes, cognitive impairment, comorbid disorders, and substance abuse in BD (Burdick et al., 2022; Gitlin and Miklowitz 2017; Nabavi et al., 2015). Similar factors, including residual depressive symptoms, impact functioning and risk of relapse in patients with UD (Romera et al., 2013; Nierenberg et al., 2010; Sheehan et al., 2017). In the ICF personal factors defined as “coping styles, past and current experience and overall behaviour pattern” (WHO 2001) are identified as variables that affect functioning. The potential role of personal factors, such as personality traits, coping strategies and experiences of childhood trauma, is less elucidated in the context of functioning in patients with affective disorders. The prevalence of childhood trauma is higher in patients with affective disorders (Vibhakar et al., 2019; Dualibe and Osório 2017) compared with the general population (Gilbert et al., 2009). The negative impact of childhood trauma is well established (Barczyk et al., 2023; Bourassa et al., 2023; Wegman and Stetler 2009), and childhood trauma was linked to functional impairment in a recent review, although based on limited evidence (Fares-Otero et al., 2023). Personality traits are stable patterns of behavior, feelings and thoughts (Conley 1984), of which neuroticism is a well-established predictor of negative outcomes. Neuroticism is the predisposition to experience psychological stress and a tendency to experience negative affect with higher levels indicating a more emotionally unstable individual prone to mood changes (Eysenck Hanse, 1975). Neuroticism and maladaptive coping strategies such as emotion-oriented and avoidance coping are associated with worse outcomes in patients with affective disorders (Christensen and Kessing 2005; Dodd et al., 2019; Liao et al., 2019; O'Connor et al., 2023). Additional research is needed to clarify the role of personal factors in predicting functional outcomes and the role of potential risk factors contributing to the lack of functional improvement seen in a large group of patients with affective disorders.

We performed the study Affective disorders: eliminate WArning signs And REstore functioning (AWARE) (Schwarz et al., 2022), a randomised controlled trial with blinded outcome assessment, investigating the effects of a personalised multimodule intervention targeting functioning (called the AWARE intervention) compared with treatment as usual (TAU) in patients with affective disorders. In summary, the AWARE intervention was superior to treatment as usual in improving secondary outcomes of cognition and stress but not regarding the primary outcome of functioning. Factors such as cognition, physical health and activities of daily living (ADL) ability were specifically targeted by the intervention. Thus, the negative results on functioning in the AWARE trial led us to explore the effects of other factors, such as personal factors, on functional impairment.

In the present exploratory study, the aims were to 1) identify factors associated with functional impairment at baseline and 2) identify predictors of improvement in performance-based functioning measured at six months follow-up. We hypothesised that early age of onset, more affective episodes, and higher affective symptom scores are associated with more functional impairment at baseline and less functional improvement at six months). We further hypothesised that higher neuroticism scores, maladaptive coping styles, and more childhood trauma are associated with more functional impairment at baseline and with less functional improvement at six months.