Triggers of mania and depression in young adults with bipolar disorder

Abstract

Background

Early intervention significantly decreases the impact of bipolar disorder. However, there is little research investigating triggers that may be unique precipitants of manic/hypomanic episodes, and how these may differ from triggers specific to bipolar depression, in young adults with the disorder.

Methods

Individuals aged 18 to 30 years who had been diagnosed with bipolar disorder (n=198) completed an online survey to identify triggers unique to mania/hypomania and depression, as well as triggers which were common to both. Respondents rated how frequently a series of situations and behaviours had precipitated either a manic/hypomanic episode or a depressive episode in the past. Survey data was supplemented by in-depth face-to-face interviews (n=11).

Results

Triggers specifically associated with the onset of manic/hypomanic episodes included falling in love, recreational stimulant use, starting a creative project, late night partying, going on vacation and listening to loud music. Triggers associated with depressive episodes included stressful life events, general stress, fatigue, sleep deprivation, physical injury or illness, menstruation and decreases in physical exercise. A further set of triggers were identified as being common to both manic/hypomanic and depressive episodes. Consistent themes arose from the analysis of face-to-face interviews, which extended and illuminated the findings of the survey data.

Conclusions

Identification of a unique set of triggers for mania/hypomania and a unique set for depression in young adults with bipolar disorder may allow for earlier identification of episodes, thus increasing opportunities for early intervention.

Introduction

Bipolar disorder has been ranked as the sixth leading cause of disability in the world, with relapse rates reportedly as high as 37% within the first year and 73% over five years. It has the highest suicide rate of all psychiatric conditions, with approximately 26% of patients attempting suicide (Mitchell et al., 2004), and up to 19% dying from such attempts (Goodwin and Jamison, 1990, Isometsa, 1993).

It is known that both genetic (Craddock and Jones, 1999) and psychosocial factors (Johnson et al., 2008) precipitate the onset of the disorder and subsequent episodes. Persistent periods of low mood, anergia, anhedonia and feelings of worthlessness are common to bipolar depression, putting individuals at risk of self-harm and suicide. Precipitants of depressive episodes include stress resulting from negative life events (Johnson, 2005, Johnson and Roberts, 1995) as well as high rates of expressed emotion (i.e., a hostile, emotionally over-involved communication style) displayed by family members or caregivers (Miklowitz et al., 1988).

Bipolar disorder is also characterised by periods of impulsivity, disinhibition and overconfidence. These manic/hypomanic episodes are known to escalate quickly and cause significant disruption to the lives of individuals and their families. While research into the triggers of depressive episodes is expanding rapidly, there has been relatively little research into the precipitants of mania/hypomania. In a recent review of the scientific literature (Proudfoot et al., 2010), goal-attainment events, antidepressant medication, disrupted circadian rhythms, seasonal factors and childbirth were identified as precipitating episodes of mania/hypomania in individuals across the age range. Tentative evidence has also been found for stressful life events and perceived criticism from others (Goodwin and Jamison, 1990, Mansell and Pedley, 2008). Studies have also identified sleep deprivation, stress, fatigue, jet lag, hormonal fluctuations, seasonal predilections, all-night partying and recreational drug use (Proudfoot et al., 2010, Russell and Browne, 2005). In addition, the likelihood of developing hypomania has been found to be up to eight times greater in the post-partum period, compared to the months leading up to childbirth (Heron et al., 2009). Case reports have also implicated St. John's Wort (Nierenberg et al., 1999), non-penetrating head injuries (Clark and Davison, 1987), guanfacine hydrochloride (Horrigan and Barnhill, 1998), shift work (Wehr et al., 1987), having an abortion (Mahe et al., 1999), driving through the night (Wehr et al., 1987), energy drinks (Machado-Vieira et al., 2001) steroid nasal sprays (Goldstein and Preskorn, 1989), alcohol and recreational stimulant drugs (Parker, 2008) as precipitants of mania/hypomania in individuals with bipolar disorder.

Bipolar disorder is commonly diagnosed during the late teens and mid twenties, and intervention programs implemented in the initial stages of the disorder can decrease the impact of illness progression (Berk et al., 2010). Hence, it is important to identify precipitants of mood episodes that are most pertinent to young adults with the disorder. However, to date there have been no comprehensive investigations into precipitants of mania and depression in young adults specifically. Therefore the aim of the current study was to identify ‘real world’ triggers of manic/hypomanic and depressive episodes in young adults aged 18 to 30 years, using both quantitative and qualitative methods. A secondary aim was to distinguish unique precipitants of mania from those which may precipitate episodes of both mania and depression.