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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 2  |  Issue : 4  |  Page : 260-263

Study of socio-demographic profile, phenomenology, course and outcome of bipolar disorder in Indian population


1 Department of Psychiatry, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
2 Department of Psychiatry, Nalanda Medical College, Patna, Bihar, India

Date of Web Publication7-Feb-2014

Correspondence Address:
Santosh Ramdurg
Department of Psychiatry, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.126729

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  Abstract 

Context: Though many researchers have made an attempt to study the phenomenology, clinical syndromes, course of bipolar mood disorder. However there was no orderliness in the research pursuit of understanding this disorder in the Indian context. Aims: Assessment of socio-demographic profile, age of onset, phenomenology, course and outcome of patients with bipolar disorder in south Indian population. Settings and Design : This prospective-retrospective study was done in a general hospital psychiatric unit including both out-patient and in-patients. Materials and Methods : All patients were diagnosed with bipolar disorder during out- and in-patient setting was evaluated by using the semi-structured questionnaires and standard tools for socio-demographic profile, age of onset, phenomenology and course and outcome in-patients with bipolar disorder. Results: In 100 bipolar patients socio-demographic data suggest mean age of presentation was 34 years, with majority being males, married, belonging to Hindu religion and were from rural background. Mean age of onset of illness was 27 years total mean number of episodes were 5.26 ± 7.4 (mania: 3.72 ± 5.2, depression: 2.1 ± 1.3). Majority had 2-5 episode (n = 62) commonly followed by recurrent mania (n = 22). Mean duration of symptoms were 116.2 ± 145.2 days in depression and 109.3 ± 124.9 days in mania. Two-third reduction in symptomatology was seen in 80% of in-patients at the time of discharge. Conclusions : Recurrent mania was a commonly observed phenomenon and duration of suffering in both phases (depression and mania) was nearly 4 months. We need long-term follow-up of these group of patients for better course and outcome data from developing country.

Keywords: Bipolar disorder, course, outcome, phenomenology


How to cite this article:
Ramdurg S, Kumar S. Study of socio-demographic profile, phenomenology, course and outcome of bipolar disorder in Indian population. Int J Health Allied Sci 2013;2:260-3

How to cite this URL:
Ramdurg S, Kumar S. Study of socio-demographic profile, phenomenology, course and outcome of bipolar disorder in Indian population. Int J Health Allied Sci [serial online] 2013 [cited 2019 Sep 21];2:260-3. Available from: http://www.ijhas.in/text.asp?2013/2/4/260/126729


  Introduction Top


Bipolar affective disorder (BPAD) disorder is one of the serious mental disorders characterized by alternating or concurrent depressive and manic symptoms that may be accompanied by psychotic symptoms with intercurrent periods with or without major affective symptoms. The presentations of the disorder can be polymorphic. Apart from the classical manic-depressive course increasingly data supports that the illness can have varied courses. The lifetime prevalence of bipolar disorder ranges from 2% to 5%, depending upon the diagnostic criteria employed. There is also growing agreement among the experts that the varied symptom profile may be explained more scientifically when the illness is considered spectrum illness namely bipolar spectrum disorder. [1],[2],[3] Several drugs and even different drug groups, acting on different receptors and having different mechanism of action are effective in the management of the condition due to the concurrence of different symptom complexes. [4],[5]

Though many researchers have made an attempt to study the nosology, clinical syndromes, course and pharmacological management of bipolar mood disorder but there were no orderliness in the research pursuit of understanding this disorder in the Indian context. [6] We wanted to know what proportion of our patients have rapid cycling, or mixed episodes? Are bipolar two disorders patients more common in general hospital psychiatry settings? How common is unipolar mania? How common is the chronicity? Do patients recover completely between episodes? There are very few studies from India where they have explored above raised questions.


  Aims and Objective Top


The aim of this study is to assess socio-demographic profile, age of onset, phenomenology and course of bipolar disorder in South Indian population.


  Materials and Methods Top


This study was carried out in a private sector hospital attached to a Medical College in Northern part of Karnataka, India. The center is one of the major health service providers in this part of Karnataka. This was a prospective cross sectional study conducted from October 2010 to March 2012 after Institutional Ethics Committee approval. Consent of the care taker/guardian was taken. Information was obtained from patients and as well as from key informants. All the cases were evaluated by consultant psychiatry after detailed work-up by resident. Consecutive out-patient and in-patients that fulfilled the inclusion and exclusion criteria were included into the study. The patients with lifetime diagnoses of BPAD, in partial remission or having active symptoms from, either sex, of any age willing to give informed consent were included in the study. Subjects with current or lifetime diagnoses of schizophrenia, schizoaffective disorder, mental retardation, autism, those with disability hampering the communication or the patients/family members not willing to give the consent and those having mood disorders secondary to substance abuse, medical conditions, or use of medications were excluded from the study. International Classification of Diseases-10-Diagnostic Criteria for Research was employed for making diagnosis of BPAD. [6]

To measure the age of onset - The self-reported questionnaire included (1) age of onset of first depressive symptoms associated with dysfunction, (2) age of onset of first hypomanic or manic symptoms and (3) age of first treatment for either mania or depression. To measure socio demographic data, a self-reporting socio-demographic performa was used. To measure the phenomenology and course of illness, National Institute of Mental Health-Life Chart Methodology (NIMH-LCM) was used. [7] The NIMH-LCM is a generally accepted instrument for follow-up studies of BPAD. In this method, the changes of mood are graphically presented and other factors, such as medication, hospitalizations, or life events, can be added in order to evaluate the causes and consequences of mood variation. We used Hamilton's Rating scale for depression (HAM-D) to measure the severity of depression and Young's Mania rating Scale (YMRS) to measure mania severity. Both are internationally accepted valid.


  Results Top


During the study period, we recruited 100 patients. At the time of inclusion all of them were having active symptoms. We used HAM-D to measure depression and YMRS to measure mania. The mean age of presentation was 34 years (ranging from 17 to 73 years), with the majority belonging to male gender, married, of Hindu religion, from rural background, having mean education of 9 th standard and farmer or housewife by occupation [Table 1]. Mean age of onset of illness was 27 years (ranging from 12 to 70 years). There was a single episode of mania present in 18 cases, 2-5 in 62 cases and 6-10 in 10 cases. Rapid cycling was seen in eight, ultra rapid in two, mixed in four and recurrent mania in 22 cases. In the majority of cases, illness had begun with a manic episode followed by depression (n = 48) and mean number of episode were 5.26 (±7.4) (ranging from 1 to more than 45).
Table 1: Socio demographic data

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Depressive episodes were observed in 58 cases (majority had 1-2 episode) with mean 2.1 episodes ranging from 1 to 6 episodes [Table 2]. Mania/hypomania was present in all the cases as it was essential to make BPAD diagnosis. 64 cases had 1-2 episodes of mania/hypomania, 3-5 episodes in 22 cases and rest had higher number of episodes. Mean number of manic episode was 3.72 (±5.2) ranging from 1 to 25 days among whom 68 cases required admission [Table 3]. Most of them required 1 month of admission in both manic and depressive phase. Time duration required to resolve depressive symptoms was 116.2 ± 145.2 days with median of 60 days ranging from 20 to 730 days. In mania, it was 109.3 ± 124.9 days with median of 90 days ranging from 7 to 730 days [Table 3]. Symptoms of respective phases of mania or depression persisted in the majority up to 3 months 80% of the inpatients at the time of discharge were near normal and rest were in partial remission (reduction in the symptoms below 50% but not became symptomatic). In out-patients two-third patients were in full remission (a state of minimal or no symptoms) and rest were either in partial remission or still have active symptoms (symptoms reduction <50%).
Table 2: Phenomenology

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Table 3: Course of bipolar illness

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  Discussion Top


The highlight of the study was the setup in which it was conducted. There are very few studies conducted in General Hospital Psychiatry Unit (GHPU) in non-governmental sector from India by using details of the studied parameters. The patient profile in GHPU and the mental hospital settings in developing countries like India vary considerably due to several factors including stigma, referral patterns, understanding of the physicians from other fraternities etc., We used the standard tools to confirm the diagnosis and NIMH-LCM to verify the course of illness. Though the majority of findings matched with the existing literature, few differed providing few new insights.

Socio-demographic data showed Bipolar illness occurring commonly in young, having usual onset in mid-twenties of life (27.38 ± 12.7 years) but could occur at any age (12-70), which was comparable with previous literature. [8] Higher prevalence of bipolarity was seen in persons with lower education, housewives, farmers and in those from rural background. Typicality in our sample was observed for the parameter of marriage wherein most of the subjects were married. This could be primarily due to strong family concept in Indian society with most of them believing that marriage can cure mental illness. India is male dominated society where majority of them are sole bread earning person. If they became mentally ill then entire family is being affected. Probably due to this, treatment seeking is more in males than females. [9]

Lifetime mean number of episode were 5 ranging from 1 to >45. This was matching with Solomon et al. study where mean number of episode were 5.5, median was 4 with the range of 1-21 and Chopra et al. study where mean number of episode were 4.4 In our sample mean number of depressive episode was 2.1 with range of 1-6 and in mania 3.7 with a range of 1 to >25. [7],[8] This finding matched with recently published study by Martin-Carrasco et al. 2012. [9] They evaluated 235 patients and found mean number of lifetime prior manic episodes as 3.9 and depressive episodes as 2.4.

Majority of subjects suffered 2-5 episodes and 6-10 episodes in lifetime comparable to other studies in Indian setting. [10] The current study observed that majority of subjects had a diagnosis of recurrent mania (n = 11), started with first episode of mania followed by depression (n = 24) and suffered from more number of manic episodes than depression, which was contrary to the findings reported by Western studies but matched with few Indian studies. [11],[12],[13],[14] This finding may be because of the fact that, in Indian culture depressive episodes may have remained under recognized and considered to be a normal variant of shanti (Calmness), which is being measured as a mental state of peace in accordance to Hindu mythology. Although in mania, because of its distinctly abnormal presentation, it could have been well recognized by the relatives. Another reason for the finding could be because our sample represented more number of males and young people who tend to have more manic episodes. [15]

In our sample, majority had only 1-2 episodes of depression (n = 38) and 1-2 episodes mania (n = 64). This finding is matching with other studies from developing countries. [10]

Mean duration of depressive episode was 116.2 days (~4 months) with range of 20-730 and in mania mean illness duration was 109.3 days (~3½ months) ranging from 7 to more than 730 days. Similar findings have been observed by Angst and Sallero (2000) reporting an average episode duration of 3-6 months. Although the authors did not distinguished between depressive and hypomanic or manic episodes. [16],[17]

Only 58 patients suffered with depressive episode and 24 patients got admitted to ward while in mania 68 patients got admitted. This also shows willingness to admit by the relatives during manic phase compared to depression and cultural and societal values for admission in private set up. Mean duration of ward stay was more in depressive episode compared to maniac episode depicting that manic phase responded well with treatment and patients were discharged early. The study by Martin-Carrasco et al. on 235 manic patients shows the median length of stay was 18 days (range: 1-73 days). [9]

The current study is limited in generalization as it was a cross sectional assessments done only on treatment seeking population without any prospective follow-up.


  Conclusion Top


Bipolar disorder in India affects majorly males, majority suffering with more number of manic episodes and both manic as well as depressive phases of illness last an average of 3-4 months. Though major findings from our study are matching with the studies from developing countries (like recurrent mania), but few findings have differed. A long-term follow-up is needed for better knowledge on course and outcome of bipolar disorder from developing country setting.

 
  References Top

1.Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995;34:454-63.  Back to cited text no. 1
    
2.Angst J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 1998;50:143-51.  Back to cited text no. 2
    
3.Szádóczky E, Papp Zs, Vitrai J, Ríhmer Z, Füredi J. The prevalence of major depressive and bipolar disorders in Hungary. Results from a national epidemiologic survey. J Affect Disord 1998;50:153-62.  Back to cited text no. 3
    
4.Licht RW. Drug treatment of mania: A critical review. Acta Psychiatr Scand 1998;97:387-97.  Back to cited text no. 4
    
5.Sachs GS. Bipolar mood disorder: Practical strategies for acute and maintenance phase treatment. J Clin Psychopharmacol 1996;16:32S-47.  Back to cited text no. 5
    
6.The ICD-10: Classification of Mental and Behavioural Disorders, Diagnostic Criteria for Research. Geneva: World Health Organization; 1993.  Back to cited text no. 6
    
7.Solomon DA, Leon AC, Coryell WH, Endicott J, Li C, Fiedorowicz JG, et al. Longitudinal course of bipolar I disorder: Duration of mood episodes. Arch Gen Psychiatry 2010;67:339-47.  Back to cited text no. 7
    
8.Chopra MP, Kishore Kumar KV, Subbakrishna DK, Jain S, Murthy RS. The course of bipolar disorder in rural India. Indian J Psychiatry 2006;48:254-7.  Back to cited text no. 8
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9.Martin-Carrasco M, Gonzalez-Pinto A, Galan JL, Ballesteros J, Maurino J, Vieta E. Number of prior episodes and the presence of depressive symptoms are associated with longer length of stay for patients with acute manic episodes. Ann Gen Psychiatry 2012;11:7.  Back to cited text no. 9
    
10.Rao PG. An overview of Indian research in bipolar mood disorder. Indian J Psychiatry 2010;52:S173-7.  Back to cited text no. 10
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11.Denicoff KD, Leverich GS, Nolen WA, Rush AJ, McElroy SL, Keck PE, et al. Validation of the prospective NIMH-Life-Chart Method (NIMH-LCM-p) for longitudinal assessment of bipolar illness. Psychol Med 2000;30:1391-7.  Back to cited text no. 11
    
12.Khanna R, Gupta N, Shanker S. Course of bipolar disorder in eastern India. J Affect Disord 1992;24:35-41.  Back to cited text no. 12
    
13.Khess CR, Das J, Akhtar S. Four year follow-up of first episode manic patients. Indian J Psychiatry 1997;39:160-5.  Back to cited text no. 13
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14.Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, Solomon DA, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002;59:530-7.  Back to cited text no. 14
    
15.Kumar R, Ram D. Evolution of symptoms of mania. Indian J Psychiatry 2001;43:235-41.  Back to cited text no. 15
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16.Judd LL, Akiskal HS, Schettler PJ, Coryell W, Endicott J, Maser JD, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003;60:261-9.  Back to cited text no. 16
    
17.Angst J, Sellaro R. Historical perspectives and natural history of bipolar disorder. Biol Psychiatry 2000;48:445-57.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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