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Predominant Polarity of Bipolar Patients in Israel

Authors:
  • Ben-Gurion University of the Negev, Beer Sheva Mental Health Center

Abstract

Studies in European and American populations have suggested that the course of bipolar illness is most often characterised by a predominance of depressions over manias. The current chart review study suggests that among manic-depressive patients in Southern Israel, a predominately manic course of illness is more common. Unlike some previous studies, no sex differences were noted in type of illness course. Possible explanations for the main finding, including climate-related factors, are discussed.
... DPP is more commonly represented in European and American populations (Judd et al., 2003;Llorca et al., 2013;Nivoli et al., 2011;Gonzalez-Pinto et al., 2010;Rosa et al., 2008) in up to 2/3 of the PP group (Etain, 2011). On the other hand, other studies have suggested an opposite pattern with a higher prevalence of a predominately manic course of illness (Osher et al., 2000;Chopra et al., 2006;Baldessarini et al., 2012). ...
... Among the 356 bipolar patients, 17.4% met the criteria for DPP, and 11.5% met the criteria for MPP. These results are in line with studies taking into account a broader BD patient sample spectrum, which reported a higher prevalence of DPP (Garcia-lopez et al. 2009;Volkert et al., 2014), and in contrast with the work of Baldessarini et al., (2012), Mazzarini et al., (2009), Osher et al., (2000, and Pacchiarotti et al., (2013), which included only BDI subjects and reported a higher prevalence of MPP. ...
... In addition to the above mentioned use of more vs. less restrictive criteria for defining PP, the different prevalence of PP, as well as the large variability in the prevalence of manic or depressive polarity in different countries may depend on a variety of factors, such as the influence of climate (Osher et al., 2000), with MPP being relatively more prevalent in warmer climate, as well as cultural (e.g. presence of the need to immigrate, which favours people with bipolar spectrum versus the obsessive spectrum, or cyclothymic or hyperthymic temperament versus anankastic temperament. ...
Article
Background: The concept of predominant polarity (PP) is defined as presenting more symptoms of one polarity. Previous studies have defined PP as one polarity (either a depression or mania episode) occurring during at least two-thirds of the lifetime. Methods: We conducted an observational study with the COPE-BD (Clinical Outcome and Psycho-Education for Bipolar Disorder, Clinical Outcome Measures Section) dataset to identify the diagnostic and treatment differences between bipolar disorder (BD) patients with and without PP. Results: The final sample included 210 BD-I (59.0%) and 146 BD-II (41.0%) patients. Of these, 28.9% patients presented predominant polarity (PP): 62 (17.4%) of those patients were depressed polarity predominant (DPP), 41 (11.5%) were manic polarity predominant (MPP), and 253 (71.1%) met criteria for bipolar disorders but did not present with PP. In comparison to this group of BD patients with undetermined polarity, the group of BD patients with PP presented more rapid cycling. Furthermore, in the undetermined polarity group, the onset of illness occurred earlier, and the duration of the illness was longer, with more hypomanic/manic and depressive episodes than patients who met the PP criteria. Limitations: This study has a naturalistic and retrospective design and does not allow a specific follow-up of polarity over time. Conclusions: These different clinical characteristics underline the importance of considering PP in patients with BD, and justify the need for differential treatment approach which could have an impact on patients' prognosis. Yet, more independent and prospective research is needed to confirm these findings, especially with the new classification of DSM-5 concerning mixed states.
... Predominant polarity was discussed for the first time by Leonhard (Leonhard, 1963) but the concept was formulated by Jules Angst (Angst, 1978) and operationalised by other authors (Osher, Yaroslavsky, el-Rom, & Belmaker, 2000;Colom et al., 2006;Daban, Colom, Sanchez-Moreno, Garcia-Amador, & Vieta, 2006;Rosa et al., 2008;Garcia-Lopez, De Dios-Perrino, & Ezquiaga, 2009;Mazzarini et al., 2009;Tohen et al., 2009;Vieta et al., 2009;Nivoli et al., 2011;Baldessarini et al., 2012b;Pacchiarotti et al., 2013). Two types of BD predominant polarity have been described: the depressive and the manic. ...
... Almost half of BD patients are associated with a predominant polarity (Rosa et al., 2008;Mazzarini et al., 2009;Vieta et al., 2009;Baldessarini et al., 2012b), however it seems that this percentage depends on the method and the sample (especially the stage of the illness). Of those with predominant polarity present, the majority are classified as having depressive polarity but the rates vary widely (Osher et al., 2000;Judd et al., 2003;Perlis et al., 2005;Colom et al., 2006;Goikolea et al., 2007;Rosa et al., 2008;Mazzarini et al., 2009;Vieta et al., 2009;Gonzalez-Pinto et al., 2010;Nivoli et al., 2011;Baldessarini et al., 2012a;Baldessarini et al., 2012b;Pacchiarotti et al., 2013;. ...
... There does not seem to be any difference in terms of drug abuse comorbidity between the two subtypes Gonzalez-Pinto et al., 2010; or disability , although in general the predominantly depressive group has a worse prognosis especially in terms of treatment response (Gonzalez-Pinto et al., 2010). Finally, it has been reported that the depressive predominant polarity is related with female gender Baldessarini et al., 2012a) and the manic with male , although other studies did not confirm this finding (Osher et al., 2000;Colom et al., 2006;Rosa et al., 2008;Mazzarini et al., 2009;Vieta et al., 2009;Gonzalez-Pinto et al., 2010;Baldessarini et al., 2012a). In the current BD patients sample there was no difference between the two subgroups in terms of gender. ...
Article
Objective: Advanced parental age might constitute a risk factor for various disorders. We tested whether this concerns also mood disorder patients. Methods: The study included 314 subjects (42 bipolar-BD patients; 21 manics and 21 depressives, 68 unipolar-UD, and 204 normal controls-NC). Analysis of Covariance (ANCOVA) and the calculation of the Relative Risk (RR) and the Odds Ratio (OR) were used for the analysis. Results: Paternal age differed between NC and UD patients (29.42 ± 6.07 vs. 32.12 ± 5.54; p = .01) and manics (29.42 ± 6.07 vs. 35.00 ± 5.75; p = .001) and maternal age between NC and manics (25.46 ± 4.52 vs. 31.43 ± 4.75; p < .001) and manic and UD (31.43 ± 4.75 vs. 26.75 ± 6.03; p = .002). The RR and OR values suggested that advanced parental age constitutes a risk factor for the development of mood disorders. Conclusions: In a non-dose dependent and gender-independent, advanced parental age constitutes a risk factor for the development of BD with index episode of mania (probably manic predominant polarity); only advanced paternal age constitutes a risk factor for the development of UD and BD with index episode of depression (probably depressive predominant polarity). This is the first study suggesting differential effect of advanced parental age depending on predominant polarity of BD.
... DPP is more commonly represented in European and American populations (Judd et al., 2003;Llorca et al., 2013;Nivoli et al., 2011;Gonzalez-Pinto et al., 2010;Rosa et al., 2008) in up to 2/3 of the PP group (Etain, 2011). On the other hand, other studies have suggested an opposite pattern with a higher prevalence of a predominately manic course of illness (Osher et al., 2000;Chopra et al., 2006;Baldessarini et al., 2012). ...
... Among the 356 bipolar patients, 17.4% met the criteria for DPP, and 11.5% met the criteria for MPP. These results are in line with studies taking into account a broader BD patient sample spectrum, which reported a higher prevalence of DPP (Garcia-lopez et al. 2009;Volkert et al., 2014), and in contrast with the work of Baldessarini et al., (2012), Mazzarini et al., (2009), Osher et al., (2000, and Pacchiarotti et al., (2013), which included only BDI subjects and reported a higher prevalence of MPP. ...
... In addition to the above mentioned use of more vs. less restrictive criteria for defining PP, the different prevalence of PP, as well as the large variability in the prevalence of manic or depressive polarity in different countries may depend on a variety of factors, such as the influence of climate (Osher et al., 2000), with MPP being relatively more prevalent in warmer climate, as well as cultural (e.g. presence of the need to immigrate, which favours people with bipolar spectrum versus the obsessive spectrum, or cyclothymic or hyperthymic temperament versus anankastic temperament. ...
... An alternative threshold has been used by a minority of authors, which considered patients to have a predominant polarity when the total number of episodes of one pole (e.g., depressive) exceeded the total number of episodes of the opposite pole (≥51% excess of one polarity) [21][22][23][24]. Two studies [25,26] used both definitions of predominant polarity. ...
... By default, the PP 50% group would be subsumed into the PP 2/3 group. We chose to consider also the 50% predominant polarity criterion as some authors previously suggested to be less stringent in defining this course specifier, which is easier to use in clinical practice [21][22][23][24][25][26]. ...
Article
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Background and Objectives: Predominant polarity (PP) may be a useful course specifier in at least a significant proportion of patients with Bipolar Disorder (BD), being associated with several clinically relevant correlates. Emerging evidence suggests that the concept of PP might influence the selection of maintenance treatments, based on a drug polarity index (PI) which measures the greater antidepressive vs. antimanic preventive efficacy of mood stabilizers over long-term maintenance treatment. In this study, we aimed to validate the PI in a large sample of Italian BD patients with accurate longitudinal characterization of the clinical course, which ensured a robust definition of the PP. Materials and Methods: Our sample is comprised of 653 patients with BD, divided into groups based on the predominant polarity (manic/hypomanic predominant polarity—MPP, depressive predominant polarity—DPP and no predominant polarity). Subsequently we calculated the mean total polarity index for each group, and we compared the groups. Results: When we examined the mean PI of treatments prescribed to individuals with DPP, MPP and no predominant polarity, calculated using two different methods, we failed to find significant differences, with the exception of the PI calculated with the Popovic method and using the less stringent criterion for predominant polarity (PP50%). Conclusions: Future prospective studies are needed in order to determine whether the predominant polarity is indeed one clinical factor that might guide the clinician in choosing the right mood stabilizer for BD maintenance treatment.
... In 11 of the 16 selected articles a quite restrictive criterion was used based on two thirds of the relapses [5][6][7][8][9][10][11] (also called the Barcelona Criteria), [5] according to which, for a patient to have a MPP at least two thirds of his relapses must have been of this type and likewise for the DPP. Other authors shifted the cut-off point to 50%, [12][13][14] while the rest only took relapse into account in absolute terms [15,16]. After analysing each of the criteria, the most restrictive definitions are more recommendable, since they are more stable over the time and the associations with clinical and therapeutic variables are more reliable. ...
... Regarding the prevalence, between 42% and 71% of the patients of the selected sample could be classified according as PP, with a median of around 50%. MPP seems more likely in cases of type 1 BD [12,17] and its frequency of presentation is slightly lower than that of DPP, which in turn is also more frequent in type 2 BD [5,6]. The fact that it is impossible to detect PP in all the patients may be explained by the fact that it does not really exist in all patients, but it may also have been significantly influenced by the absence of common criteria among professionals to apply it. ...
... Previous studies done from India, too suggest that the PP in the Indian context is that of manic (79.3%), with only a small proportion of patients have depressive PP [12]. Our findings support the previous studies from India, which have reported manic PP, and those which have reported more number of manic episodes than the depressive episodes [12,[25][26][27][28]. Studies from Asia in general suggest higher prevalence of mania, when compared to depression [12]. ...
Article
Aim This cross-sectional study aimed to assess the predominant polarity (PP) in patients with bipolar disorder (BD) and the factors associated with PP. Methodology For this study, 773 participants with at least 10 years of illness, were recruited from 14 centres, were evaluated using the National Institute of Mental Health- Retrospective Life Charts to assess the predominant polarity. Results According to Barcelona proposal for PP, 20.6% of the patients belonged to depressive PP, 45.8% belonged to manic PP and 33.6% belonged to indeterminate polarity. According to Harvard index of PP, 31.6% of the patients belonged to depressive PP, 56.1% belonged to manic polarity and 12.3% of the patients could be categorized into any of these categories and hence, were considered to have indeterminate polarity. Those with depressive PP were more often having BD-II, had later age of onset, spent more time in episodes, had higher residual depressive symptoms, had lower residual manic symptoms, more often had depression as the first lifetime episode, and less often had at least one psychotic episode. Conclusion In the Indian subcontinent, although the prevalence of PP is influenced by the definition used, the most common PP is that of mania.
... The mania-predominant illness course of our patients contrasts with the depression-predominant course patterns of bipolar disorder reported in the Western literature (Judd et al., 2002;Solomon et al., 2010). However, we observed that mania seems to predominate the course of bipolar illness prevalent in many tropical regions (Aghanwa, 2001;Osher et al., 2000;Rangappa et al., 2016). Researchers have proposed that the geographical predisposition of such regions could induce a mania-predominant course pattern by exposing the population to longer durations of sunlight (Narayanaswamy et al., 2014). ...
Article
Stressful life events can precipitate relapses and recurrences in bipolar disorder. Kindling in bipolar disorder has been linked to maladaptive psychological reactivity to minor stressful life events. Systematic studies on life events and kindling are rare in bipolar disorder with a manic predominant polarity. One hundred and forty-nine remitted patients with bipolar I disorder were recruited. The National Institute of Mental Health-Life Chart Methodology was used to depict the illness course retrospectively, and the Presumptive Stressful Life Events Scale-Lifetime version was used to record the stressful life events. The role of stressful life events and the probability of kindling were assessed using appropriate statistics. There was a mania-predominant course of bipolar disorder in the sample with 55.7% (n = 83) having only recurrent mania. Family conflict and altered sleep patterns were the commonly reported stressful life events. When controlled for the severity of the stressor, the stressful life events were often associated with the initial episodes rather than the latter ones. Kindling may occur in bipolar disorder with mania as the predominant polarity. However, retrospective recall bias and hospital-based sampling limit generalizability of such observations.
Article
Objectives Predominant polarity (PP) is a concept used to define patients with bipolar disorder (BD) as presenting a tendency to manifest depressive (DPP) or manic (MPP) episodes. Still, the high percentage of patients with an undetermined PP (UPP), has been overlooked in most studies. Thus, we aimed to study UPP and outline its socio-demographic, clinical, and treatment-related features. Methods Patients were recruited from a BD specialized unit. The sample was divided into three groups according to PP and socio‐demographic and clinical variables were compared. Significant variables at univariate comparisons were included in multivariate logistic regression with UPP as the dependent variable. Results A total of 708 BD patients were included, of which 437 with UPP (61.7%). UPP was associated with a higher number of affective relapses, when compared with DPP or MPP (χ2= 28.704, p<0.001). Mixed episodes (OR=1.398; CI=1.118–1.749), aggressive behaviour (OR=1.861; CI=1.190–2.913), seasonality (OR=2.025; CI= 1.289–3.501) and treatment with lamotrigine (OR= 2.101; CI=1.244–3.550) were significantly associated with UPP at the logistic regression. Limitations Recall bias may have occurred due to mixed episode diagnostic criteria change over the years. No data on the patients’ follow-up has been reported on predominant polarity changes. Conclusions UPP is associated with a higher number of relapses, and different clinical variables related to a severe course of illness. Considering PP in patients with BD may guide the choice for differential treatment approaches having an impact on BD course of illness and patients' prognosis and recovery.
Chapter
The concept of predominant polarity (PP) appears to be an important course specifier for bipolar disorder (BD). Despite this, it was not included in the DSM-5 as a specifier for BD. A unifying definition and conceptualization of PP is lacking. A PP is present in approximately half of BD patients. The depressive PP has been consistently associated with a depressive onset of illness, a delayed diagnosis of BD, type II BD, and higher suicidality. The manic PP is associated with a younger onset of illness, a first episode manic/psychotic and a higher rate of substance abuse. PP appears as a valid neurobiological endophenotype in the characterization of BD that provides relevant information for clinicians. Neurobiological research supports the potential utility of predominant polarity not only as a clinical but also as a neurobiological specifier in BD. Future research should clarify the potential use of predominant polarity as a biological marker.
Article
Introduction Current classification of bipolar disorder (BD) in type I or type II, however useful, may be insufficient to provide relevant clinical information in some patients. As a result, complementary classifications are being proposed, like the predominant polarity (PP) based, which is defined as a clear tendency in the patient to present relapses in the manic or depressive poles. Methods We carried out a search in PubMed and Web of Science databases, following the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses – PRISMA – guidelines, to identify studies about BD reporting PP. The search is updated to June 2016. Results Initial search revealed 907 articles, of which 16 met inclusion criteria. Manic PP was found to be associated with manic onset, drug consumption prior to onset and a better response to atypical antipsychotics and mood stabilisers. Depressive PP showed an association with depressive onset, more relapses, prolonged acute episodes, a greater suicide risk and a later diagnosis of BD. Depressive PP was also associated with anxiety disorders, mixed symptoms, melancholic symptoms and a wider use of quetiapine and lamotrigine. Limitations Few prospective studies. Variability in some results. Conclusion PP may be useful as a supplement to current BD classifications. We have found consistent data on a great number of studies, but there is also contradictory information regarding PP. Further studies are needed, ideally of a prospective design and with a unified methodology.
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A representative sample of 95 hospitalized bipolar manic-depressive patients was followed up from 1959 to 1975. The mean age of the group at the time of this study was 61 years. It was observed that female bipolar patients demonstrate depression much more frequently than mania, while male patients show a symmetric distribution of both manic and depressive syndromes. The longitudinal occurrence of syndromes remains more or less constant; for instance, individual patients do not tend to go into depression with increasing age. The study shows that even after three episodes 29% of all bipolar patients would still have been misdiagnosed as unipolar depression. An attempt is made to classify bipolar patients into three subtypes, 'preponderantly manic,' 'preponderantly depressed,' and a 'nuclear' type. Male patients belong mainly to the latter with an equal proportion of the first and third subtype. In contrast, female patients belong mainly to the depressed subtype. The findings are discussed assuming either a heterogeneity of bipolar disorders or a threshold model of affective disorders suggested by Gershon et al. (1976).
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A representative sample of 95 hospitalized bipolar manic-depressive patients was followed up from 1959 to 1975. The mean age of the group at the time of this study was 61 years. It was observed that female bipolar patients demonstrate depression much more frequently than mania, while male patients show a symmetric distribution of both manic and depressive syndromes. The longitudinal occurrence of syndromes remains more or less constant; for instance, individual patients do not tend to go into depression with increasing age. The study shows that even after three episodes 29% of all bipolar patients would still have been misdiagnosed as unipolar depression. An attempt is made to classify bipolar patients into three subtypes, ‘preponderantly manic,’ ‘preponderantly depressed,’ and a ‘nuclear’ type. Male patients belong mainly to the latter with an equal proportion of the first and third subtype. In contrast, female patients belong mainly to the depressed subtype. The findings are discussed assuming either a heterogeneity of bipolar disorders or a threshold model of affective disorders suggested by Gershon et al. (1976).
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Using data gathered in a naturalistic study of 95 research patients at the NIMH, a retrospective method of documenting the life course of recurrent affective illness is presented, along with a partial prospective validation of this method. In these patients, the severity, frequency, and duration of manic and depressive episodes, as well as their pattern and distribution, are characterized. These variables are examined in different patients subgrouped according to gender and age of onset, polarity, and rapidity of cycling of illness. The findings are compared with data on the life course of affective illness found in studies from the pre-pharmacologic era.