Elsevier

Journal of Affective Disorders

Volume 188, 1 December 2015, Pages 257-262
Journal of Affective Disorders

Research report
American tertiary clinic-referred bipolar II disorder compared to bipolar I disorder: More severe in multiple ways, but less severe in a few other ways

https://doi.org/10.1016/j.jad.2015.09.001Get rights and content

Highlights

  • Bipolar II compared to bipolar I disorder can be more severe in multiple ways.

  • Bipolar II compared to bipolar I disorder can be less severe in a few different ways.

  • Further studies warranted to determine contributors to occurrence of more severe forms of BDII.

Abstract

Background

Prevalence and relative severity of bipolar II disorder (BDII) vs. bipolar I disorder (BDI) are controversial.

Methods

Prevalence, demographics, and illness characteristics were compared among 260 BDII and 243 BDI outpatients referred to the Stanford University BD Clinic and assessed with the Systematic Treatment Enhancement Program for Bipolar Disorder Affective Disorders Evaluation.

Results

BDII vs. BDI outpatients had statistically similar prevalence (51.7% vs. 48.3%), and in multiple ways had more severe illness, having significantly more often: lifetime comorbid anxiety (70.8% vs. 58.4%) and personality (15.4% vs. 7.4%) disorders, first-degree relative with mood disorder (62.3% vs. 52.3%), at least 10 prior mood episodes (80.0% vs. 50.9%), current syndromal/subsyndromal depression (52.3% vs. 38.4%), current antidepressant use (47.3% vs. 31.3%), prior year rapid cycling (33.6% vs. 13.4%), childhood onset (26.2% vs. 16.0%), as well as earlier onset age (17.0±8.6 vs. 18.9±8.1 years), longer illness duration (19.0±13.0 vs. 16.1±13.0), and higher current Clinical Global Impression for Bipolar Disorder-Overall Severity (4.1±1.4 vs. 3.7±1.5). However, BDII vs. BDI patients significantly less often had prior psychosis (14.2% vs. 64.2%), psychiatric hospitalization (10.0% vs. 67.9%), and current prescription psychotropic use, (81.5% vs. 93.0%), and had a statistically similar rate of prior suicide attempt (29.5% vs. 32.1%).

Limitations

American tertiary bipolar disorder clinic referral sample, cross-sectional design.

Conclusions

Further studies are warranted to determine the extent to which BDII, compared to BDI, can be more severe in multiple ways but less severe in a few other ways, and contributors to occurrence of more severe forms of BDII.

Introduction

Bipolar disorder (BD) has been conceptualized as a spectrum of related conditions with recurring mood fluctuations (Akiskal and Mallya, 1987, Cassano et al., 1999) and variable prevalence, onset age, course, severity, episode frequency, comorbidity, suicide risk, and treatment response (Ketter, 2010).

Lifetime population prevalence comparison studies between bipolar II disorder (BDII) and bipolar I disorder (BDI) have shown variable results. For example, lifetime prevalence of BDII compared to BDI was slightly higher in the United States National Comorbidity Survey replication (1.1% and 1.0%, respectively) (Merikangas et al., 2007), but marginally lower in a more recent international community survey (0.40% vs. 0.46% respectively) (Merikangas et al., 2011). Nevertheless, some authors contend that BDII may be more common than BDI (Angst, 1998, Parker and Fletcher, 2012).

The older belief that BDII represented a milder form of illness than BDI, which may have been based, at least in part, upon the definition of hypomania implying, per se, less severe mood elevation compared to mania, has been increasingly questioned. Thus, studies have found that BDII compared to BDI can in multiple ways be more severe, as evidenced by more common associations with unfavorable illness characteristics, including more depressive (Endicott et al., 1985, Judd et al., 2003a, Judd et al., 2003b) and overall (Vieta et al., 1997, Goodwin and Jamison, 2007) episodes, more anxiety disorder comorbidity (Rihmer et al., 2001, Henry et al., 2003), more frequent rapid cycling course (Maj et al., 1999, Baldessarini et al., 2000, Kupka et al., 2003), and more family history of mood disorders (Endicott et al., 1985; Benazzi, 2004). Moreover, BDII compared to BDI has been associated with a greater risk of suicide attempt in some (Dunner et al., 1976, Rihmer and Pestality, 1999, Baek et al., 2011) but not all studies (Novick et al., 2010, Valtonen et al., 2005, Merikangas et al., 2011). In contrast, studies have continued to find that BDII compared to BDI in a few ways can be less severe, as evidenced by less common associations with prior psychosis (Vieta et al., 1997) and psychiatric hospitalization (Vieta et al., 1997, Bega et al., 2012).

Other clinical features that have been reported to differ between BDII and BDI patients, but require additional confirmation include: a lower rate of prescription psychotropic ingestion (Coryell et al., 1985, Endicott et al., 1985), and more alcohol abuse in women (Goodwin and Jamison, 2007). Additional parameters that are even less clearly characterized with respect to BDII vs. BDI differences include age at onset, duration of illness, lifetime number of mood elevation episodes, rate of comorbid personality disorders, and recent/current clinical status.

Some studies reported a significantly higher population prevalence of BDII in women (Merikangas et al., 2011) and clinical prevalence of female gender in BDII (Mantere et al., 2004), although most studies did not find any significant gender difference in population prevalence (Diflorio and Jones, 2010). Of note, a higher clinical prevalence of alcohol abuse has been reported in female BDII compared to BDI patients (Goodwin and Jamison, 2007).

Associations with multiple unfavorable illness characteristics, high rates of delayed diagnosis, increased latency to appropriate treatment, and related poor responses can make BDII particularly challenging (Altamura et al., 2010a, Altamura et al., 2010b). Ultimately, such factors may significantly contribute to the very substantial disability and human and economic costs associated with BDII, which are comparable to those reported for BDI and MDD (Benazzi, 2001, Judd et al., 2003b, Joffe et al., 2004, Judd et al., 2005).

In view of the variability in findings, better characterization of differences between BDII and BDI is needed. Specifically, better understanding is needed regarding which patient characteristics contribute importantly to more severe forms of BDII. Such characterization could help inform the treatment of BDII, which is commonly extrapolated from that of BDI and/or MDD, not infrequently yielding suboptimal outcomes. Thus, we assessed clinical prevalence, demographics and illness characteristics in patients with BDII compared to BDI who were referred to an American tertiary BD clinic.

Section snippets

Methods

The current analysis included outpatients with BDII and BDI, referred by community practitioners (primarily psychiatrists) to the Stanford University Bipolar Disorder Clinic between 2000 and 2011. In order for the analysis to reflect phenomenology and treatment as encountered in the community (as opposed to as encountered in a BD research clinic), patients referred from the Stanford University Bipolar Disorder Research Program or previously treated in the Stanford University Bipolar Disorder

Results

Socio-demographic and clinical features for the BDII and BDI subgroups and the entire study sample are reported in Table 1.

Among 503 BD outpatients (mean±SD age 35.6±13.1 years; 58.3% female; with illness duration 17.7±13.1 years; CGI-BP-OS score 3.9±1.5, and taking 2.6±1.7 prescription psychotropics, including benzodiazepines), patients with BDII compared to BDI had statistically similar prevalence (51.7% vs. 48.3%, binomial test, 260 BDII, 243 BDI, df=1, p=0.48) and more severe illness in

Discussion

Results from the present study suggest that in our sample, BDII compared to BDI, had statistically similar prevalence, and was more severe in multiple ways, including more frequently having lifetime anxiety and personality disorder comorbidity, current syndromal/subsyndromal depression, at least 10 prior mood episodes, prior year rapid cycling, childhood onset, a first degree relative with mood disorder, and current antidepressant administration, as well as earlier onset age, longer illness

Role of funding source

This research was supported by the Pearlstein Family Foundation the Mitchell Foundation, and the Holland Foundation; the funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Acknowledgment

These data were presented at the 166th Annual Meeting of the American Psychiatric Association in San Francisco, California, May 18–22, 2013.

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