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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 40  |  Issue : 3  |  Page : 127-136

Predictors and prevalence of bipolar disorders in patients with a major depressive disorder


1 Department of Psychiatry, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
2 Abbasia Mental Hospital, Ministry of Health, Cairo, Egypt

Date of Submission10-Jul-2019
Date of Acceptance22-Jul-2019
Date of Web Publication19-Nov-2019

Correspondence Address:
MD Rania A Hamed
Department of Psychiatry, Faculty of Medicine for Girls, Al-Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_22_19

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  Abstract 


Introduction Onset of bipolar disorder (BD) involves a major depressive episode (MDE) in approximately half of type-I (BD-I) patients and three-quarters of those diagnosed with type-II (BD-II).
Aim To detect the soft signs and the predictors of BD in patients with a MDE.
Participants and methods A sample of 500 patients was solicited fulfilling the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for a current MDE. Patients were given the HCL-32-R2 questionnaire to assess the presence of manic/hypomanic symptoms; those scoring less than 14 were considered bipolar. We also examined whether demographics, psychiatric history, clinical characteristics, and the incidence of comorbid conditions differed significantly between patients with BD and unipolar disorder.
Results A number of factors were highly predictive of bipolarity, including age at illness onset, family history of bipolarity, seasonality, mixed state, manic switch, mood irritability, and mood reactivity. Of the comorbidities examined, thyroid disorders, cardiovascular disorders, generalized anxiety disorder, presence of psychotic features, and borderline personality disorder occurred at a higher rate in patients with BDs than in those with unipolar disorders.
Conclusion A number of factors in the patient’s psychiatric history as well as clinical aspects of the episode itself may signal an increased likelihood of bipolarity.

Keywords: bipolar affective disorder, major depressive disorder, predictors, prevalence


How to cite this article:
Ismail RM, Mohamed HT, Hamed RA, Helal SA. Predictors and prevalence of bipolar disorders in patients with a major depressive disorder. Egypt J Psychiatr 2019;40:127-36

How to cite this URL:
Ismail RM, Mohamed HT, Hamed RA, Helal SA. Predictors and prevalence of bipolar disorders in patients with a major depressive disorder. Egypt J Psychiatr [serial online] 2019 [cited 2019 Dec 13];40:127-36. Available from: http://new.ejpsy.eg.net/text.asp?2019/40/3/127/271300




  Introduction Top


Onset of bipolar disorder (BD) involves a major depressive episode (MDE) in approximately half of type-I (BD-I) patients and three-quarters of those diagnosed with type-II (BD-II).

The symptoms of major depressive disorder are characterized by an overwhelming feeling of sadness, isolation, and despair that lasts 2 weeks or longer at a time. Depression is not just an occasional feeling of being sad or lonely, like most people experience from time to time. Instead, a person who has depression feels like they have sunk into a deep, dark hole with no way out, and there is no hope for things ever changing. A person who experiences a major depressive disorder must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2-week period (Bressert, 2019).

Bipolar affective disorder (BPAD) is characterized by periods of prolonged and profound depression alternate with periods of excessively elevated mood and irritable mood, known as mania (Tondo et al., 2014).

ICD 10 needs at least two mood episodes before a bipolar diagnosis can be considered, with complete recovery in between the episodes. The depressive episode must be present at least for 2 weeks, mania for 7 days (fewer if hospitalized), hypomania for 4 days, and mixed episodes for 2 weeks before they can be diagnosed using ICD 10. In DSM-IV, BD can be diagnosed even with a single manic episode (Ghaemi, 2008).

BPAD is divided into two main broad types;
  1. Type 1 is characterized by full-blown mania or mixed mania and depression;
  2. Type 2 is characterized by recurrent depression and hypomania without episodes of either mania or mixed states (Ghaemiet al., 2010).


Onset of BD involves a MDE in approximately half of type-I (BD-I) patients and three-quarters of those diagnosed with type-II (BD-II) (Baldessarini et al., 2014).

Nonetheless, studies carried out in psychiatric and primary care settings have found that BD is sometimes under-recognized, particularly in patients presenting for treatment of depression (Goldberg et al., 2005).

Even for those patients diagnosed with BD, the time lag between initial treatment seeking and correct diagnosis often exceeds ten years. Yet, the treatment implications of failure to promptly recognize BD in depressed patients include under-prescription of mood-stabilizers, an increased risk of rapid cycling, increased cost of care owing to ineffective treatment, and increased risk for suicide (Zimmerman et al., 2008).

To date, several factors have been proposed as possible predictors of the diagnosis of BD, essentially by comparing early clinical characteristics of patients and eventually meeting diagnostic criteria for a bipolar versus unipolar depressive disorder worldwide, including Egypt (Okasha et al., 2013).

Among other approaches, recommendations for improving the detection of BD include careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires which are aimed at tagging some of the most clinically sound predictive factors of eventual subthreshold bipolarity (Nusslock and Frank, 2011).

The Hypomania-Check-List 32-item, and its subsequent revisions/translations up to the latest (final 2008 module: CRF 05FEB08) 34-item second revision (HCL-32-R2) have been broadly adopted across different languages and cultural settings as part of the ‘Bipolar Disorders: Improving Diagnosis, Guidance, and Education’ worldwide study (Angst et al., 2011).


  Aim Top


The aim was to detect the soft signs and the predictors of BD in patients with a MDE.


  Participants and methods Top


Between October 2016 and October 2017, the study was held on a consecutive series of both male and female patients attending the outpatient psychiatric clinic of Abbasia Mental Health Hospital. Patients were included in the study after giving written informed consent. The written consent was taken from the patients after explaining the nature and the aim of the study. The sample consisted of both male and female patients aged between 18 and 50 years diagnosed with major depressive disorder and suffering from MDE at the time of admission to the study.

Patients suffering from ‘mood disorder due to a general medical condition’, ‘substance-induced mood disorder’, and other mental disorders like schizophrenia and other psychotic disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR); those at a high risk of an imminent suicide attempt (like patient with clear plan for suicide, availability of a tool which can be used for suicide with the patient and previous suicidal attempts); and patients with acute medical condition (like acute renal failure, acute respiratory failure, or myocardial infarction) were not included in the study.

Procedures

All patients included in the study were subjected to the following procedures:
  1. Semistructured interview: complete psychiatric history with emphasis on previous response to antidepressants, number of previous episodes, sex, age of first depressive episode, current psychiatric comorbidities, and hypomania/mania among first-degree relatives.
  2. Structured Clinical Interview for DSM-IV (SCID-I) (Arabic version) (El Missiryet al., 2004), which is a structured interview used to diagnose DSM-IV Axis I disorders.
  3. Beck Depression Inventory (Arabic version) (Abdel-Khalek, 1996), which is a tool used to measure the severity of depression.
  4. Hypomania Self Rating Scale-(Arabic version) (HCL-32-R2) (Fornaroet al., 2015) which is a questionnaire used to identify hypomanic features in patients with major depressive disorder.


Statistical analysis

The statistical package for the social sciences (SPSS version 21.0, Armonk, NY: IBM Corp) was used for data entry and analysis. Descriptive statistics were computed in the form of frequency and percentage for categorical data and in the form of measures of central tendency (arithmetic mean) and measures of dispersion (SD) for continuous variables. χ2-Test was used to test for the association and/or difference between categorical variables. Fisher’s exact test was applied instead of χ2-test if the frequency in at least one cell was less than five. Student’s t-test was used for comparing two means. Regression analysis was carried out to identify the significant risk factors. Differences were considered as statistically significant when the P value was less than 0.05.


  Results Top


This is a descriptive-analytical, cross-sectional comparative study conducted on 500 participants selected from the outpatient psychiatric clinics of Abbassia Mental Health Hospital, located in eastern region of Cairo, Egypt.

The studied sample was subjected to Arabic module of the SCID-I, Bipolar disorder type I (BDI), and finally, HCL-32-R2, which was administered to mother-tongue Arabic major depressive disorder (MDD) cases between October 2016 and October 2017. Using a cutoff of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined patients with MDD between ‘true unipolar’ (HCL-32-R2−) and ‘subthreshold bipolar depression’ (HCL-32-R2+). Accordingly, the studied sample was classified into two subgroups:
  1. Truly unipolar group.
  2. Subthreshold bipolar depression group.


The results included descriptive results and comparative results:

Descriptive results

  1. Sociodemographic data and illness factors (using the semistructured interview).


[Table 1] shows sociodemographic data of our sample.
Table 1 Sociodemographic characteristics

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The average age was 38. Overall, 36.4% of the studied population were college graduates, and only 15% were illiterate, with nearly equal distribution between males and females. More than half of the studied sample was employed. The marital state was distributed fairly evenly between both males and females.

[Table 2] shows patients’ presentation of depression (using the semistructured interview).
Table 2 Patient presentation of depression

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Of the eight symptoms of depression assessed in this study, all patients exhibited at least five, with 30.8, 28.8, and 25.6% exhibiting five, six, and seven symptoms, respectively. The vast majority (98%) reported depressed mood.

[Table 3] shows patients’ psychiatric history:
Table 3 Patient psychiatric history

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The most common age for psychiatric symptoms to be first diagnosed was between 20 and 29 years (48.6%) followed by those belonging to age group 30–39 years (26.8%). History of suicidal attempts was positive in 14.6%.

[Table 4] shows the frequency of current patient treatment (obtained from the complete psychiatric history).
Table 4 Frequency of current patient treatment (obtained from the complete psychiatric history)

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This table shows the frequency of current patient treatment. The most common of which were antidepressants (98.6%). Benzodiazepines were the most common anxiolytic drug prescribed (18.4%), and selective serotonin reuptake inhibitors (SSRIs) were the most common antidepressant (63.4%). Valproate was the most commonly prescribed mood stabilizer, at a frequency of 10.2%.

[Table 5] shows the frequency of current patient psychiatric comorbidity (SCID-I).
Table 5 Frequency of current patient psychiatric comorbidity

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Psychiatric comorbidity analysis also done and revealed that the most common of which was anxiety disorder (24.4%). The most common anxiety disorder was generalized anxiety disorder at 13.3%.

Comparative results

In this section, the study sample was divided into two groups through using the HCL-32-R2 applied with a cutoff value of 14.
  1. Truly unipolar patient group [n=167 (33.4%)].
  2. Subthreshold bipolar patient group [n=333 (66.6%)].


[Table 6] shows the sociodemographic characteristic distribution between the truly unipolar and the subthreshold bipolar groups using the semistructured interview:
Table 6 Sociodemographic characteristics distribution between the truly unipolar and the subthreshold bipolar groups using the semistructured interview

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This table displays the sociodemographic characteristics distribution between the truly unipolar and the subthreshold bipolar groups. Here it is found that none of the sociodemographic characteristics were predictive of bipolarity, as there is no statistically significant difference between both groups.

[Table 7] shows the association between illness factors and probability of having BD.
Table 7 Association between illness factors and probability of having bipolar disorder

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This table shows that there is a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding the age at illness onset and the total duration of illness (P=0.01 and 0.012, respectively).

[Table 8] shows the frequency distribution of mood disorder between the truly unipolar and the subthreshold bipolar groups according to severity of depression using Beck depression inventory.
Table 8 Frequency distribution of mood disorder between the truly unipolar and the subthreshold bipolar groups according to severity of depression using Beck depression inventory

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This table shows that there is no statistically significant difference between truly unipolar and potentially bipolar groups regarding the frequency distribution of mood disorder severity.

[Table 9] shows the frequency distribution and association between the truly unipolar and the subthreshold bipolar groups according to the symptoms of depression using Beck depression inventory.
Table 9 Frequency distribution and association between the truly unipolar and the subthreshold bipolar groups according to symptoms of depression using Beck depression inventory

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This table shows no statistically significant difference between truly unipolar and potentially bipolar groups regarding the frequency distribution of depressive symptoms.

[Table 10] shows the frequency distribution between the truly unipolar and the subthreshold bipolar groups according to patient psychiatric history.
Table 10 Frequency distribution between the truly unipolar and the subthreshold bipolar groups according to patients’ psychiatric history

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This table showed that there is a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding positive family history of BD, manic switch while on antidepressants, and seasonality of mood disorders (P=0.001 for each).

However, we found no statistically significant difference between truly unipolar and subthreshold bipolar groups regarding history of suicidal attempts, with P value of 0.71.

[Table 11] shows the frequency distribution between the truly unipolar and the subthreshold bipolar groups according to course of the disease using Beck depression inventory.
Table 11 Frequency distribution between the truly unipolar and the subthreshold bipolar groups according to course of the disease using Beck depression inventory

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This table shows that there is a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding the number of mood episodes in the past year, the number of days with depression in the past year, and the total number of suicidal attempts (P=0.016, 0.025, and 0.01, respectively). However, we found no statistically significant difference between truly unipolar and subthreshold bipolar groups regarding previous psychiatric hospitalization (P=0.9).

[Table 12] shows the frequency distribution and association of most frequent somatic comorbidity between the truly unipolar and the subthreshold bipolar groups according to patient psychiatric history. This table shows that there is a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding having cardiovascular disorders and thyroid disorder. However, there is no statistically significant difference between truly unipolar and subthreshold bipolar groups as regards other somatic comorbidities.
Table 12 Frequency distribution and association of most frequent somatic comorbidity between the truly unipolar and the subthreshold bipolar groups according to patient psychiatric history

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[Table 13] shows the frequency distribution and association of most frequent psychiatric comorbidity between the truly unipolar and the subthreshold bipolar groups using SCID-I. This table shows that there is a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding comorbidity of generalized anxiety disorders, borderline personality disorders, psychotic features, and panic disorders (P=0.001, 0.009, 0.06, and 0.001, respectively). However, there is no statistically significant difference between truly unipolar and subthreshold bipolar groups regarding the comorbidity of obsessive compulsive disorder, with P value of 0.2.
Table 13 Frequency distribution and association of most frequent psychiatric comorbidity between the truly unipolar and the subthreshold bipolar groups using Structured Clinical Interview for DSM-IV-I

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[Table 14] shows the frequency distribution between the truly unipolar and the subthreshold bipolar groups according to modality of treatment obtained from psychiatric history. This table shows that there was a statistically significant difference between truly unipolar and subthreshold bipolar groups regarding use of Benzodiazipines (BDZ), SSRIs, atypical antipsychotics, and mood stabilizers (P=0.002, 0.001, 0.001, and 0.001, respectively).
Table 14 Frequency distribution between the truly unipolar and the subthreshold bipolar groups according to modality of treatment obtained from psychiatric history

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On the contrary, there was no statistically significant difference between truly unipolar and subthreshold bipolar groups regarding Electroconvulsive therapy (ECT), antidepressants, and typical antipsychotics (P=0.2, 0.78, 0.76, and 0.21, respectively).


  Discussion Top


Recent studies have shown that between 21 and 26% of unipolar depressed patients in primary care settings had evidence of bipolarity after careful screening (Altinbas et al., 2014).

Approximately half of these people had never been diagnosed with BD. The under-recognition of BD is problematic as delayed diagnosis is associated with a range of negative outcomes for the individual, their families, and the society as a whole (Hirschfeld et al., 2005).

To help resolve this issue, the study was designed to try to determine the possible predictors of bipolarity in patients presenting with a MDE.

This study examines a number of characteristics of patients presenting with a MDE, which are as follows:
  1. Sociodemographic factors, for example, age distribution, sex distribution, education, occupation, marital status, and number of marriages.
  2. Illness factors, for example, age at illness onset and duration of illness.
  3. Severity of depressive illness.
  4. Various symptoms of depressive illness.
  5. Patient psychiatric history.
  6. Disease course.
  7. Somatic comorbidity.
  8. Psychiatric comorbidity.
  9. Modality of treatment.


Of the demographic factors considered, none were predictive of bipolarity. This was consistent with the majority of analyses, which failed to highlight any major differences in sex, age, or marital status between bipolar and unipolar patient groups (Wengi and Apio, 2011).

Interestingly, it was found that bipolar patients tend to have an earlier onset of psychiatric symptoms and the most common age for psychiatric symptoms to be first diagnosed was between 20 and 29 years, which was consistent with other studies reporting that the typical age at onset of BD is between 17 and 21 years (Yatham et al., 2005).

In this study, the frequency distribution of bipolar mood disorder was studied according to the severity of depression, and a nonstatistically significant difference between the truly unipolar group and the subthreshold bipolar depression group was found, indicating that there is no association between the severity of depression and the probability of having bipolar mood disorder. This finding is supported by the findings of the Japanese epidemiological trial with latest measure of BD (JET-LMBP) (Joseph et al., 2006).

Interestingly, this study revealed a large number of factors within the patient psychiatric history, which were found to be highly significant in elucidating the prevalence of bipolarity. Bipolar patients were more likely to report a positive family history of bipolar mood disorder (P=0.001), seasonality with their mood episodes (P=0.001), had manic switch while on antidepressants (P=0.001), atypical depression (P=0.001), mixed state (P=0.001), mood irritability (P=0.001), mood reactivity (P=0.003), and finally, psychomotor agitation (P=0.09).

Somatic comorbidity was also examined and none was predictive of bipolarity except for thyroid dysfunction and cardiovascular disease, as we found a statistically significant difference between both groups (P=0.001 and 0.07, respectively).

Psychiatric comorbidity analysis was also done and explored a statistically significant difference between both study groups regarding panic disorder without agoraphobia (P=0.001), psychotic disorders (P=0.06), and borderline personality disorder (P=0.009).Studies in bipolar patients (Faravelli et al., 2006) have suggested comorbidity with anxiety disorders with at least one lifetime anxiety disorder: 16% had panic disorder (with and without agoraphobia and panic attacks), 11% had phobia, and 3% had obsessive compulsive disorder. Comorbidity of anxiety disorders was not correlated with the severity of illness (Altindag et al., 2006).

According to a recent review done by Di Giacomo et al. (2017), on the relationship between borderline personality disorder and BD, ∼20% of people with type 2 BD received a borderline personality disorder diagnosis. For people with type 1 BD, ∼10% received a borderline personality disorder diagnosis. So, BD and borderline personality disorder can be considered a dual diagnosis.

Analysis of the treatment patients receiving at the time of the study was done. Most patients were being treated with more than one prescribed medication, and we recorded a statistically significant difference between truly unipolar and potentially bipolar groups regarding the use of Benzodiazipines (BDZ), SSRIs, atypical antipsychotics, and mood stabilizers (P=0.002, 0.001, 0.001, and 0.001, respectively).


  Conclusion Top


Among patients being treated for a MDE, a significant percentage may have an undiagnosed, underlying BPAD. So, physicians treating patients with major depression need to give special consideration to conducting an in-depth screening for bipolar affective disorder that utilizes multiple assessment tools. Additionally, a number of key factors within a patient’s psychiatric history and their clinical manifestations of depression may signal an increased likelihood of bipolar affective disorder.[21]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]



 

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