Abstract
Background:
Indian studies on the course and outcome of bipolar disorder (BD) are scarce and their methodologies vary. Nevertheless, differences from Western ones have been noted.
Methods:
A systematic random sample of 200 patients with BD attending a general hospital psychiatric unit was chosen. They were assessed using the clinician and self-rated versions of the National Institute of Mental Health—Retrospective Life Charts, the lifetime version of the Columbia Suicide Severity Rating Scale, the Medication Adherence Questionnaire, the Indian Disability Evaluation and Assessment Scale, and the Presumptive Stressful Life Events Scale.
Results:
The mean age of onset of BD was 26 years. About 11%–13% of the illness was spent in acute episodes, mostly in depression (60%). Episode frequency was 0.4–0.6 annually. The first episode was more likely to be manic, and manic episodes outnumbered depressive episodes. The average duration of episodes was 3 months. Depressive episodes were longer and the time spent in depression was greater than mania. Psychotic symptoms (48%), a mania-depression-interval pattern (61%), and recurrent mania (19%) were common while rapid cycling and seasonal patterns were uncommon. Comorbidity (40%), functional impairment (77%), and lifetime nonadherence (58%) were high, whereas lifetime suicide attempts (16%) were low. Stressful life events were very common prior to episodes (80%), particularly early in the illness.
Conclusion:
This study suggests differences between Indian and Western patients in the demographic profile and the course and outcome of BD. A more benign presentation in the current study including Indian studies is indicated by their later age of presentation and illness onset, higher rates of marriage, education, and employment, a mania predominant course, lower rates of rapid cycling, comorbidity, and suicidal attempts. Factors associated with better outcomes such as longer time to recurrence, Manic Depressive pattern of illness, and low rates of hospitalizations also appear to be commoner in our study and also in other Indian studies.
Keywords: Bipolar disorder, course, disability, India, life events, suicide
INTRODUCTION
Bipolar disorder (BD) is a chronic, highly recurrent illness, which is common and frequently disabling. The traditional view of bipolar disorder was that of a condition characterized by good outcomes and complete recovery from acute episodes of the illness. However, research over the past few decades has shown that the course of BD is usually characterized by multiple recurrences with incomplete remissions, persisting subsyndromal symptoms, and functional impairment.[1,2,3] Studies on epidemiology and course and outcome of BD from India are scarce.[4] In epidemiological studies, lifetime prevalance rates are 0.1% for bipolar spectrum disorders and 0.5% for BD.[5,6] These rates are considerably lower than those found in other countries, though this discrepancy is more likely to be due to differences in diagnostic practices and study designs. Studies on the course and outcome of BD from India are mostly hospital-based retrospective investigations, with many methodological shortcomings such as small numbers, nonprobabilistic sampling, and the lack of standardized assessments in many reports. Moreover, there is a relative lack of information on certain key aspects of the outcome of BD such as disability, comorbidity, medication adherence, and suicidal behavior. However, some of the more recent Indian studies that have used the National Institute of Mental Health- Retrospective Life Charts (LCM),[7] have assessed the course of BD more comprehensively among relatively larger samples of patients.[8,7,8,9,10,11,12,13,14,15,16] The findings of these LCM-based studies suggest certain differences in the course and outcome of BD among Indian patients. For example, a consistent finding across these studies is the predominance of manic as opposed to depressive pathology. Favorable demographic characteristics, later onset, low rates of rapid cycling, lower comorbidity, and less frequent suicidal attempts are some of the other findings of these studies, which are different from the Western reports.
These considerations prompted the current retrospective, longitudinal study of the long-term course, and outcome of BD among adult patients attending a general hospital psychiatric unit in India. The current study attempted to study long-term course, disability, physical and psychiatric comorbidity, stressful life events, disability, lifetime suicidal behavior, and medication adherence in BD
METHOD
Participants
This study was carried out in a general hospital psychiatric unit of a multispecialty hospital in north India, after due approval from the Institute Ethics Committee. All the participants were recruited after obtaining written informed consent and other ethical safeguards were maintained during the study. Patients had to have a confirmed diagnosis of BD-1 according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria, were required to be aged 18–65 years at intake, and ill for at least 2 years. They had to be accompanied by a clinically healthy adult family member, who was staying with the patient for the past 5 years or more and was aware of the details of the patient’s illness and treatment. If more than one healthy family member accompanied the patient and fulfilled the selection criteria as mentioned above he/she was also incorporated as an informant in the study. Patients were excluded if they had an intellectual disability, medication- or substance-induced BD, were acutely ill and not able to participate in the study, or at risk of harm to self or others.
Sampling
The participants were recruited from September 2015 to October 2016 using systematic random sampling. From a pool of 1407 patients with BD who met selection criteria, a random sample was chosen using the random numbers table and a 1:7 ratio, yielding a sample of 201 patients. Only one patient refused to consent, yielding a final random sample of 200 patients.
Assessments
Diagnosis were confirmed using the Mini International Neuropsychiatric Interview, PLUS version (MINI PLUS).[17] Demographic parameters were recorded using the standardized departmental format used in our department. The demographic details included age at intake, gender, education status, marital status, socioeconomic status, family setup, etc. Current symptom-severity was assessed using the Young mania Rating Scale (YMRS) and the Hamilton Depression Rating Scale (HDRS). No cut off value for YMRS and HDRS was used for inclusion. Information about the long-term course was recorded using the clinician and self-rated versions of the LCM.[7] LCM is an easy-to-follow method of constructing a clear picture of the course of BD. The life chart provides an overview of the number and type of past episodes, their duration, frequency of comorbid symptoms, triggering life events, hospitalization, response to treatment, and other relevant information. Information was obtained from both patients and family members. Any discrepancies between the two versions of the LCM were resolved by consulting the medical records. In the current study, remission of the particular episode was defined clinically by information obtained from patients, family members, and medical records. In addition, disability was rated using the Indian Disability Evaluation and Assessment Scale (IDEAS)[18]; lifetime suicidal behavior was rated by the Columbia Suicide Severity Rating Scale-Lifetime version[19]; medication adherence was assessed by the Medication Adherence Questionnaire (MAQ)[20]; and stressful life events were assessed by the Presumptive Stressful Life Events Scale (PSLES).[21] The PSLES is a 51-item self-report scale for listing life events relevant to Indian conditions. The participants were asked to recall the type of life events and tick the appropriate item on the scale for each episode in their lifetime. If the participants reported life events in an episode then they were marked as present for that particular episode and if not then they are marked as not present for that particular episode.
Statistical analysis
Data were analyzed by using the SPSS-14 (Statistical Package for the Social Sciences, 2005, Chicago, IL, USA). Apart from the mean, standard deviation, and median values, frequencies and percentages were also estimated. Group comparisons were carried out using the Chi-square or the Students’ t-tests.
RESULTS
Demographic profile [Table 1]
Table 1.
Demographic profile of the patients with bipolar disorder (n=200)
| Variable | Total sample: 200 Mean (SD)/n (%) |
|---|---|
| Age | 42.31 (12.12) years |
| Male | 141 (71%) |
| Currently married | 146 (73%) |
| Education: years of schooling | 10.74 (4.55) years |
| Education: 10 years and above # | 102 (53%) |
| Employed and earning ¶ | 132 (66%) |
| Socioeconomic status | |
| Upper | 29 (14%) |
| Middle | 152 (76%) |
| Lower | 19 (9%) |
| Urban residence | 107 (54%) |
| Nuclear family | 107 (54%) |
#7% of the patients were illiterate ¶ students/housewives/retired=27%
Patients were middle-aged, predominantly married men. The majority had more than 10 years of schooling, and very few were illiterate. About two-thirds were in paid employment, and about a third were either housewives, students, or retired people. Patients were predominantly from middle-class backgrounds. A little more than half of them were urban-based and from nuclear families.
Course and treatment profiles [Table 2a and b]
Table 2a.
Course and outcome of patients with bipolar disorder (n=200) #
| Variables | Mean (SD), Median, (Range) |
|---|---|
| Age of onset of bipolar illness in years | 25.91 (8.77), 23.5, (8-51) |
| Duration of illness in months | 198.98 (121.28), 168, (24-528) |
| Duration of manic episodes in months | 1.98 (1.60), 2, (0.3-14) |
| Duration of depressive episodes in months | 4.21 (5.74), 5, (1-44) |
| Duration of mixed episodes in months | 2.60 (1.63), 2, (1-6) |
| Time spent in illness in months | 26.59 (22.91), 18, (2-161) |
| Time spent in remission in months | 172.39 (116.81), 150, (0-504) |
| Time spent in mania in months | 10.95 (13.15), 6, (1-100) |
| Time spent in depression in months | 15.49 (17.66), 10, (0-102) |
| Time spent in mixed episodes in | 0.16 (0.97), 2, (0-10) |
| months | |
| Total number of episodes | 9.27 (8.98), 6, (2-58) |
| Number of manic episodes | 5.52 (6.14), 3, (1-44) |
| Number of depressive episodes | 3.68 (4.58), 2, (0-29) |
| Number of mixed episodes | 0.07 (0.49), 1, (0-6) |
| Average severity of all episodes | |
| Mild | 1.06 (02.52), 0, (0-17) |
| Moderate | 3.61 (04.46), 2, (0-24) |
| Severe | 4.61 (06.92), 3, (0-58) |
| Average severity of manic episodes | |
| Mild | 0.71 (1.69), 0, (0-11) |
| Moderate | 1.20 (2.23), 0, (0-14) |
| Severe | 3.62 (5.22), 2, (0-39) |
| Average severity of depressive episodes | |
| Mild | 0.36 (1.20), 0, (0-09) |
| Moderate | 2.35 (3.22), 1, (0-20) |
| Severe | 0.98 (2.99), 0, (0-29) |
| Average severity of mixed episodes | |
| Moderate | 0.03 (0.36), 0, (0-05) |
| Severe | 0.04 (0. 24), 0, (0-2) |
| Number of psychotic episodes | 1.07 (1.74), 0, (0-11) |
| Number of manic episodes with | 0.88 (1.64), 0, (0-11) |
| psychotic symptoms | |
| Number of depressive episodes with | 0.20 (0.55), 0, (0-4) |
| psychotic symptoms | |
| Current episode severity | |
| Hamilton Depression Rating Scale score | 6.04 (6.03), 4, (0-29) |
| Young Mania Rating Scale score | 5.25 (8.11), 3, (0-48) |
| Number of lifetime hospitalizations | 0.44 (1.12), 0, (0-10) |
| Duration of untreated illness in months | 31.74 (6.99), 30, (0-396) |
# Findings based on the Mini International Neuropsychiatric Interview-Plus and the National Institute of Mental Health—Retrospective Life Charts: clinician and self-rated versions
Table 2b.
Course and outcome of patients with bipolar disorder (n=200) #
| Variables | Frequency (%) |
|---|---|
| Diagnosis of the most recent episode | |
| BD, most recent episode mania | 97 (48%) |
| BD, most recent episode depression | 100 (50%) |
| BD, most recent episode mixed | 3 (1%) |
| Nature of first episode | |
| Mania | 122 (61%) |
| Depression | 76 (38%) |
| Mixed | 2 (1%) |
| Presence of at least one episode with psychotic symptoms | 97 (48%) |
| Pattern of illness | |
| DMI | 78 (39%) |
| MDI | 122 (61%) |
| Recurrent mania | 39 (19%) |
| Rapid cycling bipolar disorder | 5 (2%) |
| Seasonal pattern | 4 (2%) |
| Family history of mental illness | 93 (46%) |
| Lifetime hospitalizations | 54 (27%) |
| Medication (current) ¶ | |
| Mood stabilizers (lithium/valproate/others) | 180 (96%) |
| Antipsychotics | 133 (66%) |
| Antidepressants | 54 (27%) |
# Findings based on the Mini International Neuropsychiatric Interview-Plus and the National Institute of Mental Health—Retrospective Life Charts: clinician and self-rated versions. ¶ Lithium carbonate=59%, Sodium valproate=35%
The most recent episode at intake was almost equally likely to be either mania or depression while mixed episodes were much less common. Symptom scores suggested that most patients were in remission when assessed. The mean and median duration of any type of episode was about 3 months. Depressive episodes were significantly longer than manic episodes (t = 5.29; P < 0.0001) as well as mixed episodes (−t = 3.82; P < 0.001). Mixed episodes were also significantly longer than manic episodes (t = 3.84; P < 0.001). Only a small proportion of the illness, from 11% (median) to 13% (mean), was spent in acute episodes. Patients spent about 60% of the acute illness in depression, about 40% in mania, and about 1% in mixed episodes. Time spent in depression was significantly longer than that spent in mania (t = 2.92; P < 0.01). The first episode was significantly more likely to be a manic episode than a depressive one (X2 = 21.38; P < 0.001). A total of nine episodes over 17 years meant that episode frequency ranged from 0.4 to 0.6 per year. Consequently, the time to recurrence of any mood episode varied from 21 to 28 months. Manic episodes were significantly more frequent than depressive (−t = 3.407; P < 0.01) as well as mixed episodes (−t = 12.51; P < 0.0001). Depressive episodes were also more frequent than mixed episodes (t = 11.08; P < 0.0001). About half of the episodes were severe and a third were of moderate intensity. The majority (about 60%) of the manic and mixed episodes were severe while 64% of the depressive episodes were of moderate intensity. Psychotic symptoms were significantly more frequent in manic than depressive episodes (t = 5.56; P < 0.0001). However, rapid cycling and seasonal patterns were uncommon. Both the proportion of patients hospitalized and the number of lifetime hospitalizations was low. Patients had received treatment for more than 80% of their illnesses.
Other parameters of outcome [Table 3]
Table 3.
Comorbidity, disability, suicidal attempts, stressful life events, and medication adherence among patients with bipolar disorder (n=200)
| Variables | Mean (SD), Median, (Range) or Frequency (%) |
|---|---|
| Current psychiatric comorbidity (according to the MINI-Plus) | |
| Patients with any current comorbidity (past 12 months) | 86 (43%) |
| Comorbid psychiatric disorders | |
| Dysthymia (past 2 years) | 1 |
| Generalized anxiety disorder (past 6 months) | 12 (6%) |
| Panic disorder with/without agoraphobia (past month) | 39 (19.5%) |
| Social anxiety disorder (past month) | 9 (4.5%) |
| Obsessive compulsive disorder (past month) | 3 |
| Post-traumatic stress disorder (past month) | 1 |
| Any anxiety disorder (past 1-6 months) | 65 (32.5%) |
| Alcohol abuse or dependence (past 12 months) | 23 (11.5%) |
| Other substance abuse or dependence (past 12 months) | 39 (19.5%) |
| Any substance use/dependence (past 12 months) | 62 (31%) |
| Nonaffective psychotic illness (past 12 months) | 2 |
| Antisocial personality disorder | 2 |
| Lifetime medical comorbidity | |
| Patients with any lifetime medical comorbidity | 74 (37%) |
| Comorbid medical conditions | |
| Hypertension | 39 (19.5%) |
| Diabetes mellitus | 17 (8.5%) |
| Thyroid disorders | 18 (9%) |
| Others | 40 (20%) |
| Disability (according to the IDEAS) | |
| IDEAS global score over the past 2 years | 8.47 (2.65) 8 (2-15) |
| More than 40% disability (global score ≥7) over the past 2 years | 153 (76.5%) |
| Lifetime history of suicidal attempts (according to the C-SSRS) | 33 (16.5%) |
| Number of suicide attempts | 1.15 (0.36), 1, (1-2) |
| Nonsuicidal self-injurious behavior | 0.21 (0.54), 0.2, (0-4) |
| Lifetime medication adherence (according to the MAQ) | |
| Fully or partially nonadherent | 117 (58.5%) |
| Lifetime stressful life events (according to the PSLES) | |
| Number of patients with least one episode precipitated by life events | 160 (80%) |
| Number of episodes with life events 1 year prior to onset | 2.49 (1.92), 2, (1-11) |
| Commonest types of stressful life events | |
| Death of close family member | 37 (18.5%) |
| Family conflict | 37 (18.5%) |
| Change in sleep habits | 27 (13.5%) |
| Getting married or engaged | 24 (12%) |
| Trouble at work | 21 (10.5%) |
| Financial loss or problems | 19 (9.5%) |
| Broken engagement or love affair | 18 (9%) |
| Major personal illness or injury | 16 (8%) |
| Illness of family member | 16 (8%) |
| Marital conflict | 14 (7%) |
| Change in working condition | 13 (6.5%) |
| Birth of daughter | 12 (6%) |
| Failure in examinations | 12 (6%) |
MINI-Plus, Mini International Neuropsychiatric Interview-Plus; IDEAS, Indian Disability Evaluation and Assessment Scale; C-SSRS, Columbia Suicide Severity Rating Scale—Lifetime/Recent version; MAQ, Medication Adherence Questionnaire; PSLES, Presumptive Stressful Life Events Scale
Current psychiatric comorbidity was present in 43% of the patients; anxiety and substance use disorders were the two most common comorbid conditions. More than a third of the patients had a physical illness; hypertension, diabetes mellitus, and hypothyroidism were the commonest conditions. A large proportion of the patients had been functionally impaired in the 2-year period before intake, although levels of disability were mostly moderate. Rates of full or partial nonadherence were high during the patients’ lifetimes. Bereavement and family conflict were the two most common such events. The rate of stressful life events prior to episodes was higher in those with fewer episodes [Figure 1].
Figure 1.
Stressful life events reported by the participants
DISCUSSION
A brief description of the LCM-based Indian studies has been provided in the Appendix. Although the methodology of this study was similar to the other LCM-based Indian studies of BD, unlike the other studies in our study systematic random sampling was used to generate the sample and standardized instruments were used to examine all aspects of the course of the illness. Moreover, our results were based on a relatively larger randomized sample of patients, a longer duration of follow-up, and a more comprehensive assessment of different outcome parameters [Appendix].
Although the findings of the present study were largely similar to earlier Indian ones, certain important differences were also observed.
Patients of this study were in their 40s, predominantly married men, who were educated and earning, or housewives and students. They came from middle-class, urban, and nuclear family backgrounds. This profile was comparable with other Indian studies including the LCM-based ones as well as general population surveys.[6] These demographic characteristics were somewhat different from Western studies, where BD is usually associated with younger ages, an equal gender distribution, single status, lower educational levels, unemployment, and low income.[22,23] The male predominance in Indian studies could be partly, but not wholly attributable to sociocultural differences in treatment-seeking between genders. Cultural differences could also account for high rates of marriage, literacy, and employment. However, since these demographic parameters are quite likely to be consequences of BD, this raises the possibility that Indian patients may have a more benign course of the illness.
One of the possible indicators of a benign course of BD is its relatively later onset among Indian patients. The majority of Indian studies including the current one, have found an age of onset between 25 and 30 years, with only 15%–20% of the patients having an onset less than 18 years.[10,14,16] This is in contrast to the more recent Western studies, where the age of onset has generally been between 18 and 22 years[2,3,22,23,24]; the proportion of patients with early onset is also greater, and the outcome poorer in the early onset groups.[3,24] Then again, this difference could be because Indian studies are hospital-based, or because of variations in diagnostic ascertainment. However, the major difference between Indian and Western studies is in the predominance of mania among the former. Most Indian studies including the LCM-based ones have found that first episodes are more frequently manic, manic episodes outnumber depressive episodes during the illness, the duration of manic episodes and time spent in mania is greater, and the proportion of recurrent manic episodes is higher.[4,25,26] In contrast, first episodes are often depressive in Western studies, depressive episodes outnumber manic ones, the time spent in depression is greater, and recurrent manic episodes without depression are uncommon.[1,2,3,4] It has been suggested that genetic variations or environmental variables such as sunlight or latitudinal gradients could explain this discrepancy between the Indian and Western studies,[4,11,25] but it is equally likely that underestimation of depression is common in Indian studies because of their retrospective and hospital-based nature, male predominant samples, and the inability to account for differences in help-seeking.[4,8,11,26] Some of the findings of the present study, which differed from the other LCM-based Indian studies, were relevant here [Appendix]. Though the first episode was significantly more likely to be a manic one in the current study, the proportion of depressive first episodes was considerably higher than in the other studies. Similarly, though manic episodes were more frequent, the number and proportion of depressive episodes were higher, and that of manic episodes lower than the other LCM-based studies. Unlike these studies, depressive episodes were significantly longer than both manic and mixed episodes in the present study; consequently, the time spent in depression was proportionately more than that spent in mania. Finally, the proportion of recurrent manic episodes was less than most of the other Indian studies. Thus, these discrepant findings of the current study seemed to indicate that an underestimation of the extent of depression could be a likely cause of a predominantly manic course found in the other Indian studies.
In terms of other indicators of a less severe course of illness among Indian patients with BD, the findings of the present study were similar to earlier Indian studies. For example, the time to recurrence was comparable with other Indian studies, but somewhat longer than Western ones.[10,26] A rapid-cycling pattern is less commonly found among Indian patients than Western ones.[3] This has been attributed to the predominance of mania and the lower use of antidepressants in Indian patients.[11] The findings of the current study were alike on both these counts. In contrast, a higher prevalence of an MDI pattern that is often associated with a better outcome was found in this and some other Indian studies.[8] In addition, the rates of both psychiatric and physical comorbidities were similar to Indian studies, but considerably lower than those found in Western reports.[2,3] Like this study, the lifetime rates of suicide attempts are lower than Western rates in other Indian studies, including the LCM-based ones.[12] The low proportion of seasonal episodes found in this study is also a common finding in other Indian studies, unlike Western ones.[9,27]
However, certain indicators of outcome found in the present study were quite different from both earlier Indian and Western reports. For example, the proportion of episodes preceded by stressful life events was higher than most Indian as well as Western studies, although the type of events and the evidence of sensitization were similar to earlier reports.[13,28,29] Moreover, though the high rates of current treatment and nature of such treatment found in this study were similar to other Indian studies, the duration of untreated illness was less than other Indian studies.[6,11,15] Consequently, the number and proportion of patients ever hospitalized were both lower than almost all Indian and Western studies.[1,9] This could partly explain the favorable course and outcome of BD among patients of this study.
Finally, some outcome parameters of the current study resembled previous Indian and Western reports of a recurrent, chronic, and disabling course of BD. These included the number and frequency of mood episodes, their average duration, the severity of episodes, the time spent in acute episodes, the presence of a family history of mental illness in about half of the patients, high rates of psychotic symptoms, especially during manic episodes, the high proportion of patients with disability, and the high rates of medication nonadherence.[1,2,3,4]
The study had few limitations. The study was conducted in a hospital, and cannot be extrapolated to general populations. Retrospective life chart-based method may be a source of potential recall bias. However, in our study we tried to overcome this by meticulously charting the course using a standardized life chart followed by corroborating with a reliable informants and the file records of the patient maintained by the trained psychiatrists. Because of the time bound nature of the study, sample size was not calculated. Future studies with large sample size in community population should be done to improve the generalization of the study results.
In conclusion, Indian studies including the present one have suggested that there might be differences in the demographic profile and the course and outcome among patients with BD. A more benign presentation among Indian patients is indicated by their later age of presentation and illness-onset, higher rates of marriage, education and employment, a mania predominant course, lower rates of rapid cycling, comorbidity, and suicidal attempts. Factors associated with better outcomes such as longer time to recurrence, an MDI pattern of illness, and low rates of hospitalizations also appear to be commoner in Indian patients. However, it is not clear whether these differences are due to genetic factors, geographical variations, sociocultural differences, or the retrospective, and hospital-based nature of the Indian studies. Some of the discrepant findings of the current study suggest that the failure to properly elicit the level of depressive symptoms may also have played a role in the mania predominant course found in most Indian studies. These issues can only be resolved if prospective studies that are both hospital and community-based are conducted in Indian settings. Such studies should ideally be supplemented by more methodologically refined studies of the etiology of BD among Indian patients, so that the true nature of the course and outcome of BD among Indian patients can be ascertained.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
APPENDIX
APPENDIX.
Comparisons of course of bipolar disorder with other Indian retrospective life chart-based studies *
| Ramdurg et al. 2013[8] | Umamaheswari et al. 2014[9] | Karthick et al. 2015[10] | Rangappa et al. 2016[11] | Kattimani et al. 2017[12] | Subramanian et al. 2017[13] | Subramanian et al 2018[14] | Kapur et al. 2019[15] | Subramanian et al. 2020[16] | Current study | |
|---|---|---|---|---|---|---|---|---|---|---|
| Age of onset | 27.4 years | 27.8 years | 24.8 years (median 23) | 22.1 years | 24.8 years | 20% < 18 years | 21.5 years | 24.0 years | 25.9 years (median 23.5) | |
| Illness duration | 7.6 years | 14.9 years | 13.4 years (median 12) | 11.5 years | 13.4 years | 13.2 years | 13.9 years | 15.1 years | 11.8 years | 16.6 years (median 14) |
| Mania duration | 3.63 months | 2.19 months | 2.49 months (median 2) | 3.32 | 1.98 months (median 2) | |||||
| Depression duration | 3.87 months | 3.15 months | 2.26 months (median 2) | 1.38 | 4.21 months (median 5) | |||||
| Mixed episodes duration | 0.20 months | 2.45 months (median 2.5) | 2.60 months (median 2) | |||||||
| First episode | Mania 48% Depression 52% | Mania 85% Depression 15% Mixed 1% | Mania 84% Depression 14% Mixed 2% | Mania 85% Depression 15% | Mania79% Depression 18% Mixed 3% | Mania/mixed 85% Depression 15% | Mania 61% Depression 38% Mixed 1% | |||
| Episode frequency | 0.69 per year | 0.35 per year | 0.43 per year (median 0.47) | 0.72 per year | 0.52 per year | 0.40 per year | 0.52 per year | 0.45 per year | 0.48 per year | 0.56 per year (median 0.43) |
| Proportion of episodes | Mania 67% Depression 29% Mixed 4% | Mania 43% Depression 56% Mixed 0.5% | Mania 82% Depression 17% Mixed 1% | Mania 56% Depression 44% | Mania 81% Depression 18% Mixed 1% | Mania 58% Depression 42% | Mania 72% Depression 22% Mixed 5% | Mania 59% Depression 40% Mixed 1% | ||
| Time spent in acute episodes | 7% | 11% | 10% | 11% | 11% | 13% (median 11%) | ||||
| Time spent in mania | 9.31% | 4.53% | 7.92% | 5. 50% (median 4%) | ||||||
| Time spent in depression | 1.64% | 5.32% | 3.08% | 7.78% (median 6%) | ||||||
| Time spent in mixed episodes | 0.16% | 1.02% (median 1%) | ||||||||
| Recurrent mania | 22% | 53% | 48% | 56% | 19% | |||||
| Lifetime psychotic symptoms | 87% | 48% | ||||||||
| Rapid cycling | 10% | 2.3% | 2.5% | 6.3% | 2% | |||||
| Seasonal pattern | 5% | 2% | ||||||||
| Mania-depression-interval pattern | 48% | 61% | ||||||||
| Hospitalized | 82% | 30% | 27% | |||||||
| Number of hospitalizations | 3.3 | 1.7 | 0.4 |
* The National Institute of Mental Health—Retrospective Life Charts: clinician or self-rated versions
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