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Prospective Evaluation of the Impact of the COVID-19 Pandemic on the Functioning of Patients with Bipolar Disorder

Évaluation prospective de l’impact de la pandémie de COVID-19 sur le fonctionnement des patients atteints de trouble bipolaire

Rim Sellami, Hela Trigui, Sameh Elleuch, Mariem Bouhamed, Ines Feki, Jawaher Masmoudi

Department of Psychiatry A, Hedi Chaker University Hospital, University of Sfax, Sfax, Tunisia.

Correspondance : Rim Sellami — rimsellami55@gmail.com

DOI : https://doi.org/10.68500/bh.v1i2.14

Reçu : 11 août 2026 · Accepté : 28 septembre 2026 · Publié : 15 octobre 2026

1. Introduction

The initial emergence of COVID-19 in Wuhan, China, in December 2019 triggered a rapid sequence of events that soon encompassed the entire globe, spreading to virtually every country worldwide [1,2]. The World Health Organization’s declaration of COVID-19 as a pandemic on March 11, 2020, served as a global wake-up call, underscoring the severity of the situation and the urgent need for coordinated international action to contain viral transmission and mitigate its deleterious effects on public health and the global economy [3]. Healthcare professionals were severely affected by the pandemic, while government-imposed restrictions profoundly disrupted the world economy, impacting nearly all aspects of daily life [4]. This crisis disproportionately affected the most marginalized and disadvantaged population groups, particularly individuals followed for psychiatric disorders [5]. Bipolar disorder (BD) is a recurrent affective illness that is particularly sensitive to stressful life events, which are well-established risk factors for triggering new mood episodes [6]. According to the DSM-5 classification, two main subtypes are distinguished: bipolar disorder type I, defined by the occurrence of at least one full manic episode (which may be preceded or followed by hypomanic or major depressive episodes), and bipolar disorder type II, characterized by the combination of at least one hypomanic episode and at least one major depressive episode, without a full manic episode. Individuals with BD demonstrate heightened sensitivity to environmental factors, disruptions in daily routines, and the quality of social interactions [7]. These elements play a critical role in maintaining mental health stability and overall well-being [8], and are closely tied to the various domains of psychosocial functioning known to be affected in this population — namely autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time.

Interestingly, studies have reported that the initial surge in psychiatric symptoms observed during the early waves of the COVID-19 pandemic in patients with mental disorders substantially decreased as the pandemic progressed, eventually returning to pre-pandemic levels [9]. Nevertheless, patients with BD are prone to heightened reactivity to stress. During the pandemic, multiple stressors converged to create a state of chronic stress: fear of personal or loved-one infection, the relentless influx of pandemic-related information and mortality reports, job or income loss due to the economic crisis, restricted access to outdoor recreational venues, and social isolation from family and friends [10]. Some literature suggests a degree of resilience in BD patients; despite large pandemic-related increases in subjective cognitive dysfunction. In contrast, a recent review found individuals with bipolar disorder at risk of poorer physical and mental health outcomes during the outbreak owing to the lack of health and emotional support [11,12]. The authors of this review speculated that some risk factors associated with bipolar disorder, including irregular social rhythms, may be compounded by lockdowns and social isolation [12].

To date, few studies have specifically examined these well-being domains — autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time — in this population, or assessed perceived stress during the pandemic period. This raises several unanswered questions: did global psychosocial functioning in euthymic patients with BD actually change between the pre-pandemic and post-pandemic periods? If so, which specific domains of functioning were most affected? And to what extent was perceived stress, once the acute phase of the pandemic had passed, associated with impairment in these domains? It is within this context that the present study was conducted, aiming (i) to evaluate global psychosocial functioning and each of these specific domains in a cohort of euthymic patients with Bipolar Disorder (BD) before the COVID-19 pandemic (T1) and after the pandemic period (T2), and (ii) to assess perceived stress levels and their association with psychosocial functioning in these patients during the pandemic period (T2). The value of this study lies in its prospective, longitudinal design, which allows a direct, within-subject comparison of functioning before and during the pandemic — an approach still rare in the bipolar disorder literature — and in its detailed, domain-specific assessment of psychosocial functioning together with perceived stress, offering findings that could help guide the clinical management of this vulnerable population during future large-scale health crises.

2. Patients and method

Study Design and Setting

The present study was a two-phase, prospective, comparative, and analytical study conducted among patients with bipolar disorder (BD) followed at the Mood Disorders Unit of the “A” Psychiatry Department, Hédi Chaker University Hospital, Sfax, Tunisia. The study comprised two distinct assessment periods: T1 (January 2019 to June 2019) and T2 (December 2021 to May 2022), allowing a direct prospective comparison of the same patients’ functioning before and during the COVID-19 pandemic.

Study Population and Sampling

The study population consisted of patients with BD followed at the above-mentioned unit who were assessed at both T1 and T2. Sampling was non-probabilistic and consecutive (exhaustive), based on the review of all patients evaluated at T1 who met the eligibility criteria and could be re-contacted and reassessed at T2.

Inclusion Criteria

Patients were included if they:

• met the diagnostic criteria for BD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5);
• were aged >18 years;
• were in a euthymic state, with full remission for at least three months at both T1 and T2, confirmed by a score <8 on the 17-item Hamilton Depression Rating Scale (HDRS-17) and <7 on the Young Mania Rating Scale (YMRS).

Exclusion Criteria

Patients were excluded if they presented with:

• treatment discontinuation;
• a current manic or depressive episode;
• cognitive impairment or intellectual disability;
• pregnancy or postpartum status;
• a substance use disorder or another comorbid psychiatric disorder;
• one or more severe or disabling somatic illnesses.

Procedure

Eligible patients were contacted by telephone. After receiving an explanation of the study objectives and procedures and being informed of its strictly scientific nature, participants provided oral informed consent. Anonymity and confidentiality were ensured throughout the study. All participants underwent the same assessment protocol administered by the same investigator, with an average duration of 30 minutes per evaluation.

Data were collected using a structured hetero-administered questionnaire developed following a review of the literature. The questionnaire comprised a sociodemographic and clinical information sheet, psychiatric history items, COVID-19-related questions, and validated psychometric instruments.

The four pandemic waves in Tunisia were defined as follows: first wave (March–June 2020), second wave (July–September 2020), third wave (March–April 2021), and fourth wave (July–October 2021).

Assessment Instruments

Several validated instruments were used to assess the main dimensions of the study.

Depressive symptoms: The 17-item Hamilton Depression Rating Scale (HDRS-17) was used to assess depressive symptoms [13].

Manic symptoms: The Young Mania Rating Scale (YMRS) was used to assess manic symptoms [14]. The scale has been validated in French. Total scores range from 0 to 60, with higher scores indicating greater severity of manic symptoms.

Psychosocial functioning: The Functioning Assessment Short Test (FAST) was used to assess psychosocial functioning [15]. This 24-item scale evaluates six domains: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time. Each item is scored on a 0–3 Likert scale (0 = no difficulty; 3 = severe difficulty). The total score ranges from 0 to 72, with scores >11 indicating functional impairment.

Perceived stress: The Perceived Stress Scale (PSS) was used to assess perceived stress [16]. It was administered retrospectively after the fourth pandemic wave (July–October 2021), with instructions explicitly referring to stress experienced during this period. Higher scores indicate greater perceived stress [17].

Statistical Analysis and Data Processing

Data were entered and analyzed using IBM SPSS Statistics version 23. Qualitative variables were described using frequencies and percentages. The normality of quantitative variables was assessed using the Shapiro–Wilk or Kolmogorov–Smirnov tests to determine the appropriate statistical approach (parametric or non-parametric) for subsequent analyses. Normally distributed quantitative variables were expressed as means ± standard deviations (SD), with minimum and maximums values. Non-normally distributed variables were reported as medians with interquartile ranges (IQR). Comparisons of psychometric scores between T1 and T2, reflecting changes within the same patients over time, were performed using the paired Student’s t-test for normally distributed variables and the Wilcoxon signed-rank test for non-normally distributed variables. These paired tests were appropriate given the repeated-measures design of the study. Associations between two qualitative variables were assessed using Pearson’s chi-square (χ²) test when expected frequencies were ≥5, or Fisher’s exact test when expected frequencies were <5. Fisher’s exact test was used to ensure validity when expected cell counts were small. Associations between a dichotomous qualitative variable and a quantitative variable were assessed using the independent Student’s t-test for normally distributed data. Correlations between quantitative variables were assessed using Spearman’s rank correlation coefficient (rho), which is appropriate for non-normally distributed or ordinal data. For all analyses, the threshold for statistical significance was set at p < 0.05.

3. Results

Study Sample and Response Rate

Among the 72 outpatients with bipolar disorder (BD) in a euthymic state assessed at T1 (pre-pandemic), 20 patients were unreachable when contacted by telephone to complete the survey. Consequently, at T2 (post-pandemic), the final sample consisted of 52 patients, yielding a response rate of 72.2%.

Sociodemographic Characteristics

The results are presented in Table 1.

Clinical Characteristics

In this study, 80.8% of patients were diagnosed with bipolar disorder type I, while 19.2% were diagnosed with bipolar disorder type II. At T1, all patients were euthymic. The mean score on the 17-item Hamilton Depression Rating Scale (HDRS-17) was 3.0 (SD = 2.5), indicating residual depressive symptoms in 78.8% of patients, without meeting diagnostic criteria for a major depressive episode. The mean Young Mania Rating Scale (YMRS) score at T1 was 1.65 (SD = 1.45), reflecting residual (hypo)manic symptoms in 61.5% of patients.

At T2, the mean HDRS-17 score was 2.1 (SD = 1.85), with residual depressive symptoms observed in 77.0% of patients, again without fulfilling criteria for a major depressive episode. Similarly, the mean YMRS score at T2 was 1.68 (SD = 1.48), and 57.7% of patients exhibited residual (hypo)manic symptoms.

Psychosocial Functioning

At T1 (pre-pandemic):

• Median global FAST score: 15.5 (IQR = [8–29.5])
• Highest median domain scores: occupational functioning and cognitive functioning
• Global psychosocial functioning impairment (cutoff >11): 69.2% of patients
• Domain-specific impairment: occupational functioning 82.7%, cognitive functioning 75.0% (n = 39), autonomy 44.2%

At T2 (post-pandemic):

• Median global FAST score: 12.5 (IQR = [5–20])
• Highest median domain scores: cognitive functioning and leisure activities
• Global psychosocial functioning impairment (same cutoff): 59.6% of patients
• Domain-specific impairment: cognitive functioning 80.8%, occupational functioning 53.8%, leisure domain 55.8%

Perceived stress at T2: mean Perceived Stress Scale score was 13.5 (SD = 5.0); half of the sample reported a low level of perceived stress, while 44.2% reported a moderate level.

Comparison of Psychosocial Functioning Before and After the COVID-19 Pandemic (T1–T2)

Comparison of FAST scores between T1 and T2

Using a dimensional approach, the median global psychosocial functioning score decreased from T1 to T2, from 15.5 (IQR = [8–29.5]) to 12.5 (IQR = [5–20]); however, this difference did not reach statistical significance (p = 0.081). In contrast, the median occupational functioning score showed a significant decrease between T1 and T2, from 5 (IQR = [4–7.5]) to 2 (IQR = [0–3]) (p = 0.001) (Table 2).

Overall, global psychosocial functioning impairment decreased from 69.2% at T1 to 59.6% at T2, without reaching statistical significance. Among the specific domains, only occupational functioning impairment showed a statistically significant reduction in the post-pandemic period (p = 0.001), while impairments in cognitive functioning and leisure activities remained stable, with no significant change between the two time points (Figure 1).

Associations Between Perceived Stress and Psychosocial Functioning at T2

At T2, the mean score on the Perceived Stress Scale was 13.5 (SD = 5). Positive correlations were observed between post-pandemic perceived stress levels and global psychosocial functioning, as well as with all of its domains (Table 3).

4. Discussion

Psychosocial Functioning Before and After the COVID-19 Pandemic (T1–T2)

The findings of the present study contrast with much of the international literature, which has reported a deterioration in global psychosocial functioning among individuals with psychiatric disorders during the COVID-19 pandemic, particularly after the first wave [18]. These studies suggest that patients with pre-existing mental disorders are particularly vulnerable during global crises, with increased psychological distress, anxiety, depression, and emotional symptoms reported across diverse cultural contexts [6,19,20].

In contrast, our results indicate that the COVID-19 pandemic was not associated with a significant deterioration in global psychosocial functioning among euthymic patients with bipolar disorder. Although no statistically significant difference was observed between the pre-pandemic and post-pandemic assessments, a slight improvement in psychosocial functioning was observed at T2. These findings are consistent with several longitudinal studies in bipolar disorder that reported stable clinical severity or modest improvements during the pandemic period [21–23].

This relative stability may be partly related to the sociodemographic and clinical characteristics of our sample. The majority of participants were married (61.6%) and living with their families (94.2%), which may have provided a stable relational and material environment during the pandemic and potentially buffered the effects of lockdown-related social isolation. Similarly, most patients resided in urban areas (73.1%), which may have facilitated continued access to psychiatric follow-up and pharmacological treatment despite pandemic-related restrictions on movement.

The modest improvement observed in our sample may also reflect adaptation to pandemic-related disruptions and the potential role of resilience. Resilience, defined as the capacity to adapt to or recover from stressful events, has been identified as an important factor in long-term psychological adjustment during the pandemic [24,25]. Although resilience may not necessarily prevent acute pandemic-related distress, it may contribute to sustained coping over time among individuals with bipolar disorder.

Finally, the absence of a significant deterioration in psychosocial functioning between T1 and T2 may partly reflect the continuity of psychiatric care during the pandemic. Access to university hospital services, outpatient follow-up, and pharmacological treatment was maintained through organizational measures, which may have helped mitigate the potential negative effects of the health crisis on psychosocial functioning.

Psychosocial Functioning Domains Before and After the COVID-19 Pandemic (T1–T2)

Among the six psychosocial functioning domains assessed, only occupational functioning showed a statistically significant change between T1 and T2. Specifically, the median occupational functioning score decreased significantly from 5 (IQR: 4–7.5) at T1 to 2 (IQR: 0–3) at T2 (p = 0.001). Before the COVID-19 pandemic, occupational functioning impairment was observed in 82.7% of patients, compared with 53.8% after the pandemic. These findings indicate a significant reduction in occupational functioning impairment at T2 (p = 0.001), suggesting an improvement in this domain.

This finding may be partly related to the occupational profile of our sample. Most participants were professionally active (71.2%), and just over half held regular employment (51.9%). It is possible that this relatively active population, predominantly residing in urban areas, was better able to adapt to changes in work organization and flexible working arrangements introduced during the pandemic, which may have contributed to the observed improvement in occupational functioning.

In contrast, no significant differences were observed between T1 and T2 in the other psychosocial functioning domains, namely autonomy, cognitive functioning, interpersonal relationships, financial functioning, and leisure activities, or in global psychosocial functioning. Our findings are broadly consistent with previous studies. A Spanish study by González-Blanco et al. examining the impact of lockdown on individuals with severe mental disorders reported that 87.7% of professionally active participants experienced no change in employment status related to COVID-19, while 76.8% reported no change in income, with no significant difference in occupational functioning [21]. Similarly, a U.S. study by Yocum et al. found that 78.8% of patients with bipolar disorder reported no occupational or income changes related to the pandemic [26].

Individuals with mental disorders often have lower socioeconomic status and higher unemployment rates than the general population, potentially increasing their vulnerability during periods of economic instability [1,23]. Strong associations have also been reported between psychosocial functioning, social interactions, and economic stability, with poorer functioning associated with lower work productivity, fewer social contacts, and greater loneliness [11,28]. In our sample, however, most patients reported a middle socioeconomic status (71.1%), which may have provided some degree of financial protection against the economic consequences of the pandemic. This finding may indicate that patients with bipolar disorder can adapt to adverse circumstances when adequate social and material resources are available.

Nevertheless, patients with bipolar disorder have reported adaptive strategies during the pandemic, including adherence to mask-wearing, social distancing, and teleworking arrangements [4]. Despite these adaptations, individuals with bipolar disorder may also experience specific difficulties associated with teleworking, including technical and motivational challenges [29]. Distress related to remote work may therefore be particularly relevant in this population, especially in the presence of other major stressors. This burden could potentially be reduced through targeted workplace interventions, such as regular follow-up and tailored support for employees with mood disorders [29].

The maintenance of occupational functioning among patients with bipolar disorder during the pandemic may have been influenced by several contextual factors, including the expansion of teleworking, the development of small businesses, and the increased availability of online purchasing of essential goods. Teleworking may provide greater temporal and spatial flexibility, which could be beneficial for some individuals with bipolar disorder. Similarly, employment in small businesses may offer greater autonomy and flexibility in workload and scheduling, although this possibility was not directly assessed in the present study. The expansion of online purchasing may also have reduced the need for travel and face-to-face interactions during periods of viral transmission. These potential explanations should, however, be interpreted cautiously because these factors were not directly measured in our study.

Links Between Perceived Stress and Psychosocial Functioning After the COVID-19 Pandemic (T2)

Bivariate correlation analyses revealed positive associations between perceived stress at T2 and global psychosocial functioning, as well as between perceived stress and each of the specific psychosocial functioning domains. These findings are consistent with previous research showing an association between pandemic-related stress and impaired psychosocial functioning. A study conducted in Ireland in 2020 reported moderate functional impairment among participants, with 50% reporting a deterioration in mental health attributed to the pandemic and 40% reporting increased psychological distress. The greatest impact was observed in social functioning, followed by quality of life, while moderate effects were reported for anxiety and distress symptoms. Coronavirus-related restrictions were also associated with higher anxiety levels and poorer quality of life [30].

Furthermore, pandemic-related lockdown measures have been associated with episodes of sadness, with potentially greater consequences among individuals with bipolar disorder. Because individuals with bipolar disorder may have relatively limited social networks, prolonged restrictions could further reduce opportunities for social interaction. Previous evidence suggests that restricted social networks in this population are associated with greater functional impairment and prolonged recovery [6]. Consistently, findings from a multicentric study conducted in 2022 indicated that individuals with bipolar disorder experienced greater emotional effects from social distancing than individuals without mental disorders [7].

Previous studies have also demonstrated that social distancing can negatively affect psychological well-being [31], particularly among individuals with bipolar disorder, through disruptions in daily routines, employment, and social support [21,32]. Social support plays an important role in relapse prevention and the maintenance of remission in bipolar disorder [33]. Maintaining social connections may therefore be particularly important for reducing emotional distress and supporting psychosocial functioning in this population [10].

Limitations

Several limitations of this study should be acknowledged. First, the sample size was relatively modest and was recruited from a single tertiary care center, which may limit the generalizability of the findings. The response rate in the present study was 72.2%, which is comparable to rates reported in some studies conducted during the pandemic. This response rate may reflect both the challenges of maintaining clinical follow-up during a global health crisis and the willingness of patients with BD to remain engaged in research despite disruptions to routine care. Nevertheless, the loss of participants between T1 and T2 should be considered when interpreting the findings, as it may have introduced selection bias, potentially favouring patients with greater clinical stability or stronger engagement with care.

Second, perceived stress was assessed retrospectively using the Perceived Stress Scale, which may have introduced recall bias, particularly given the prolonged and evolving nature of the COVID-19 pandemic. Third, the absence of a control group, either from the general population or from patients with other psychiatric disorders, limits the ability to determine whether the observed patterns were specific to bipolar disorder.

Additionally, psychosocial functioning and clinical symptoms were assessed through telephone interviews, which, although necessary because of pandemic-related constraints, may have introduced reporting bias. Furthermore, variables such as resilience, social support, treatment adherence, and access to care were not directly measured, precluding a more detailed assessment of potential protective factors that may have influenced functional outcomes. Finally, perceived stress was assessed only at T2 and retrospectively, preventing longitudinal assessment of stress trajectories over time and limiting conclusions regarding temporal relationships between stress and psychosocial functioning.

5. Conclusion

Bipolar disorder is a condition whose prognosis largely depends on whether or not relapse episodes occur. It is increasingly evident today that the quality of a patient’s environment plays a decisive role in the course of this illness, insofar as it shapes the stability of daily routines, access to care, and the maintenance of social ties. A pandemic such as COVID-19, with its accompanying lockdowns, disruptions to routine, and uncertainty, therefore represented, a priori, a high-risk context for this population. Our study showed that the global psychosocial functioning of euthymic patients with bipolar disorder remained relatively stable throughout the pandemic period. However, perceived stress was significantly associated with functional impairment during the post-pandemic phase, revealing that the threat to this population lies not so much in the crisis itself as in the persistent psychological burden it leaves behind. These findings underscore the importance of maintaining continuity of care and addressing stress management in this vulnerable population during and after large-scale public health crises.

These elements call for a rethinking of bipolar disorder management in times of crisis: beyond the mere management of the health emergency itself, continuity of psychiatric care and the systematic integration of stress management should be placed at the heart of care for this vulnerable population, both during and after major public health crises.

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