- Bipolar Disorder and Gender Differences
- How does bipolar disorder affect women?
- General symptoms
- Do Men and Women Experience Bipolar Disorder Differently?
- Bipolar in Men vs. Bipolar in Women: Understanding Gender Differences in Bipolar Disorder
- Gender Differences in Bipolar Disorder
- Gender Differences in Incidence and Age at Onset of Mania and Bipolar Disorder Over a 35-Year Period in Camberwell, England
Bipolar Disorder and Gender Differences
Bipolar disorder develops in men and women in about equal numbers, but there are gender differences in the ways that the illness manifests itself. Women with the disorder tend to have more depressive and fewer manic episodes than men do. “The typical bipolar woman will start with a depressive episode, whereas a man will usually get a manic episode first,” says Michael First, M.D., professor of clinical psychiatry at Columbia University and editor of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s diagnostic guidelines. Women are also more likely to have bipolar II, which is a milder form of the disorder. However, women are more prone than men to rapid-cycling bipolar, which is characterized by four or more episodes of depression and mania in one year. Rapid-cycling bipolar appears to be more resistant to treatment than other forms of the illness.
Bipolar Disorder and Gender Differences: Women
Some research suggests that abnormal thyroid levels may contribute to the way bipolar disorder manifests in women. “There seems to be an elevated level of thyroid disturbances associated with rapid-cycling bipolar disorder,” says Carrie Bearden, Ph.D., a clinical neuropsychologist and associate professor of behavioral sciences and psychology at UCLA. Thyroid imbalances are more common in women than in men. Other associated medical conditions that are seen more often in bipolar women than in men include migraines, obesity, and anxiety and panic disorders.
Reproductive hormones may also play a role in bipolar disorder in women, since symptoms often worsen during perimenopause and menopause. “During perimenopause, women may be especially at risk for depressive episodes because of declining estrogen levels,” says Bearden.
Women also face the complications of managing bipolar disorder during and after pregnancy, when they appear to be more vulnerable to the condition’s symptoms. According to the National Alliance on Mental Illness, pregnant women and new moms with bipolar disorder have seven times the risk of hospitalization and two times the risk of a recurrent episode compared with women who aren’t pregnant or who haven’t recently delivered. Managing bipolar disorder during pregnancy and lactation can be a challenge because some of the medications used to treat the illness carry potential risks for developing fetuses and nursing infants. Research suggests that some anticonvulsants used to treat bipolar disorder — such as Depakote and Tegretol — can be harmful to fetuses, possibly contributing to birth defects. Lithium and first-generation antipsychotics such as Haldol and Thorazine are considered safer. Studies have found that they carry minimal risks to developing fetuses and nursing babies.
However, knowledge about the safety of bipolar medications during pregnancy and nursing is still evolving. “It’s important to discuss the risks and benefits of taking medications for bipolar disorder with your doctor if there is a possibility you may become pregnant,” advises Dr. First. It’s a delicate balancing act because depression during pregnancy can also be harmful to the health of a developing baby.
Bipolar Disorder and Gender Differences: Men
In men, bipolar disorder typically begins earlier and is more severe than in women. Manic episodes tend to be particularly pronounced. In addition, men are more apt to act out during mania. “Guys are more likely to be out drinking, fighting, and yelling at people on the street, which often lands them in jail or causes them to be hospitalized for mania,” says Bearden. Men with bipolar disorder are also more likely than women to have problems with drug or alcohol abuse. Despite severe symptoms, studies show that men are less likely than women to voluntarily seek medical care for psychological conditions, including bipolar disorder. The most serious consequence of untreated bipolar disorder is suicide — in fact, studies show that between 10 and 15 percent of people with the bipolar disorder will end their own lives. “Bipolar men are more at risk for suicide than women because suicide is more common in males,” says First.
Fortunately, bipolar disorder is a highly treatable illness. A combination of medicine and psychotherapy will reduce bipolar episodes in most patients. By working with a psychiatrist familiar with bipolar disorder, both men and women can find an appropriate treatment plan for their life stage and gender.
How does bipolar disorder affect women?
Share on PinterestWhen a woman has bipolar disorder, some research suggests that the symptoms present differently.
Bipolar disorder has a number of specific variations when women have the disorder.
According to a 2015 review, women have a higher risk of depressive symptoms than men. They may also be more likely to develop BD at a later age.
The same study suggests that BD in women might be harder to treat and recover from, as women more frequently have a co-occurring condition, including:
- anxiety disorders
- thyroid disease
A different, more recent study also showed that BD was more likely to occur alongside inflammatory disorders, including asthma, Crohn’s disease, and multiple sclerosis when presenting in women.
One study from 2015 showed that women also have a higher risk of mixed episodes, in which manic symptoms present during a depressive episode or vice versa.
Bipolar disorder involves episodes of mania and depression.
Mania might cause the following symptoms:
- high energy
- a tendency to make errors in judgment
- becoming easily distracted or bored
- frequently performing poorly at work and school, or missing it altogether
- a feeling of invincibility, as if the person with BD could do anything
- being almost aggressively social and forward
- exhilaration or euphoria
- partaking in risky behavior
- extreme confidence and self-importance
- rapid speech that switches topic erratically
- a frantic stream of thoughts
People with hypomania experience these symptoms to a lesser degree. Findings on differences between symptoms of bipolar II disorder in men and women are inconsistent.
Some clinical samples suggest that women are more likely to experience bipolar II disorders than men.
Depressive symptoms include:
- a near-daily depressed mood that lasts for a large quantity of the day, as reported by the individual themselves or observed by others
- notably reduced pleasure or interest in every activity (or almost every activity) throughout the day on a daily or near-daily basis
- weight gain or loss of more than 5% body weight, even though the individual may not be dieting
- sleep disturbances, including insomnia and hypersomnia
- observable slowing down or speeding up of speech and movement, displaying restlessness or lethargy
- daily fatigue or energy loss
- near-daily feelings of excessive and disproportionate guilt and worthlessness
- observable or self-reported inability to think clearly, focus, or make decisions
- repeatedly thinking about death with or without a specific plan around suicidal ideation, or a suicide attempt
For a diagnosis of bipolar disorder, these must cause distress or impairment to the extent that they disrupt a person’s ability to function in social, professional, other areas. The doctor must also not be able to attribute these symptoms to other conditions or substance use.
In mixed episodes, a person experiences many of these symptoms at the same time.
The symptoms of BD are complicated. To learn more, visit our page on bipolar disorder by clicking here.
Bipolar II disorder is similar to bipolar I disorder, in that a person experiences extreme emotional highs and lows.
To receive a diagnosis of bipolar I disorder, a person only needs to experience one disruptive manic episode. Some people may experience a major depressive episode, but others might not.
In bipolar II disorder, the person experiences hypomanic symptoms, which are not as severe as the manic symptoms in bipolar I disorder. A person with bipolar II disorder must also experience a manic episode.
One review suggests that rapid cycling is more common in women than in men. This is the occurrence of four or more mood episodes within 12 months. The cycles may not alternate rapidly; however — the four mood episodes can be major depressive, manic, or hypomanic.
Research suggests that these differences between men and women could relate to abnormal thyroid levels or hypothyroidism, and that imbalanced thyroid levels occur more frequently in women than in men.
People with bipolar disorder may receive an incorrect diagnosis. Some research finds that women are more likely to receive a depression diagnosis due to the prevalence of depressive symptoms.
Women and men experience sleep differently, and sleep problems are common in people with bipolar disorder. Poor-quality sleep and bipolar disorder seem to make each other worse.
For example, in one 2015 study that took place over 2 years, poor sleep was a predictor of a poor mood outcome for women but not men.
Do Men and Women Experience Bipolar Disorder Differently?
Bipolar disorder affects men and women in equal numbers, and the symptoms are essentially identical. But some key differences do exist—differences that might be due to biological factors, and social ones, too.
For starters, research has consistently shown that women have higher rates of bipolar II disorder, “which typically presents as a chronic depressive disorder with periods of hypomania,” according to Candida Fink, MD, a board-certified child, adolescent and adult psychiatrist with a private practice in Westchester, N.Y.
There’s a misconception that bipolar II disorder is less severe than bipolar I because mania can have devastating consequences—from bare bank accounts to broken relationships.
However, bipolar II disorder has unique characteristics and complications. The depressive episodes can be very severe, and hypomania also can come with painful consequences.
In the past, it was believed that women experience more depressive episodes than men, along with higher rates of rapid cycling (four or more episodes per year) and mixed episodes (simultaneously experiencing symptoms of mania and depression).
But today’s research is less clear, said Dr. Fink, co-author of several books on bipolar disorder.
Differences in Co-Occurring Conditions
What is clear is that differences do exist in the physical illnesses that strike women and men with bipolar disorder. Women with bipolar disorder have “three times higher rates of hypothyroidism compared to men,” and “three times the rate of migraine,” Fink said. Women also have “higher rates of co-occurring illnesses that are marked by dysregulations of inflammation responses— asthma, Crohn’s disease and multiple sclerosis.”
Currently, researchers are exploring the connection between bipolar disorder and inflammatory responses (“the body’s reaction to stress or injury”), Fink said. Women with bipolar disorder having higher rates of inflammatory disorders brings up various critical questions, which, she said, include: “Does this affect how women experience bipolar disorder in terms of severity of symptoms and how those symptoms affect their lives? Could this information be important in developing treatment approaches to women with bipolar disorder that may differ in some ways from treating men?”
The mental illness that co-occurs with bipolar disorder also seems to vary by gender. According to Fink, women with bipolar disorder are twice as likely as men to have PTSD, a personality disorder and anxiety disorders. Men with bipolar disorder have higher rates of substance use disorder than women, she said. Psychologist Cynthia G. Last, Ph.D, noted that men are more likely to abuse alcohol—and have problems with the law, landing in jail.
Women with bipolar disorder are two to three times more likely than men to attempt suicide, said Last, who specializes in treating individuals with bipolar disorder in Boca Raton, Fla. But “men who attempt suicide show a two to three times greater fatality rate than women.”
The Effects of Societal Perceptions
How society views emotions in men and women can influence how individuals interpret their own symptoms, how they understand bipolar disorder and whether they actually seek professional treatment, said Michael G. Pipich, MS, LMFT, a psychotherapist who specializes in mood disorders in Denver, Colo., and penned the book Owning Bipolar: How Patients and Families Can Take Control of Bipolar Disorder.
Pipich shared these examples: Bipolar disorder mood swings can get dismissed in women, because they’re seen as “typically female” issues (when really the root is “an underlying, treatable disorder that should not define a woman’s more usual and healthy disposition”). Mania can get dismissed in men because it’s misinterpreted as the traits of a “hard-driving, successful alpha-male,” he said.
Men and women also may respond differently to depression. “Generally speaking, men can be less willing to discuss the desperate and vulnerable feelings associated with depression, including low self-worth, helplessness and suicidal thoughts,” Pipich said. Consequently, they’re less likely to seek help when they’re experiencing a depressive episode than women, he added.
Periods, Pregnancy, Postpartum and Menopause
The reproductive cycle plays a pivotal role in bipolar disorder. For some women, symptoms of bipolar disorder worsen around their menstrual cycle. According to Pipich, “Each situation can be different, but many women with bipolar report an increase in irritability, restlessness, racing thoughts, pressured speech and impulsivity, which typically reflects manic symptoms.” Many also “have experienced outbursts of rage and other behaviors that are not characteristic of their usual personalities,” he said.
Other women have disclosed that they become incredibly depressed during their period, and might even have suicidal thoughts (or attempts), he said.
If they’re not taking mood-stabilizing medication, women also have reported longer, more severe episodes during their cycle, Pipich added.
Fink noted that women with bipolar disorder also have a higher risk of medical complications during pregnancy (e.g., high blood pressure) and health problems for the baby (e.g., small birth weight).
Childbirth can trigger the onset of bipolar disorder in women, or trigger a new episode in women who’ve already been diagnosed with the illness, said Last, author of the book When Someone You Love is Bipolar: Help and Support for You and Your Partner.
According to perinatal psychiatrist and researcher Dr. Verinder Sharma, “We know childbirth is perhaps the most important and most potent trigger of bipolar disorder.”
As perinatal psychotherapist and maternal mental health Amy-Rose White, LCSW, noted in this piece, postpartum bipolar disorder includes depressive episodes with possible symptoms of severe sadness, sobbing, hopelessness, guilt and lack of interest in activities moms previously enjoyed. Depressive episodes also might have symptoms of anxiety and agitation. Women might seem highly functional—baby is well taken care of—but they feel completely detached.
Depressive episodes are followed by extreme energy, rapid speech, racing thoughts about baby’s health (or something else), decreased need for sleep, and odd or out-of-character behavior, according to White.
Menopause is another powerful factor. As a whole, menopause is associated with increased mood symptoms and depression in all women. Some small studies also suggest that women with bipolar disorder may have higher rates of mood episodes during menopause, Fink said, but the research has been scarce. In fact, older women in general aren’t well represented in research studies, she said.
There are both similarities and differences in men and women with bipolar disorder—and more research is needed to understand exactly what drives some of those differences. Is it hormones? Is it an inflammatory response? Is it something else? The answers may be multilayered as bipolar disorder is a complex illness.
Either way, one of the most important commonalities is that bipolar disorder is highly treatable in both genders. The key is to seek help—and to stick with it. When you find the right treatment—a combination of medication and psychotherapy and perhaps other forms of support—you might be surprised by the incredible strides you can make.
Do Men and Women Experience Bipolar Disorder Differently?
Bipolar in Men vs. Bipolar in Women: Understanding Gender Differences in Bipolar Disorder
In truth, the best bipolar treatment is different for each individual. Ideally, a treatment plan takes into account the person’s history, symptoms, triggers, home and daily environment, available support, and personal goals and challenges. Those variables may be unique to each client.
Considering that there tend to be recognizable patterns of bipolar episodes that differ in men and women, this may inform the particulars of their clinical supervision. For example, because men tend to experience more frequent and severe episodes of mania, clinicians may place more emphasis on preparing male clients for the challenges related to mania. But, of course, this wouldn’t make the depressive episodes any less serious. In fact, because men tend to be less likely to seek treatment, it is especially important that close attention is also paid to the lows that typically follow the highs.
On the other hand, women may experience more frequent depressive episodes and more rapid cycling of mania and depression. So, psychiatrists and therapists will aim to prepare female clients to cope with these personal challenges. They may also put in place treatment strategies to weather seasonal changes, as well as hormonal and phase-of-life changes that can affect bipolar women more intensely than men.
When left untreated, bipolar disorder leaves both men and women vulnerable—to their own uncontrollable cycling and often unpredictable behaviors, to society’s misunderstanding, to a possible lack of supportive resources, to others who might take advantage. And the list goes on. But it doesn’t have to. Expert treatment programs for bipolar disorder continue to improve in ways that continue to improve the lives of men and women in recovery.
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Gender Differences in Bipolar Disorder
The presentations and clinical courses of patients with bipolar disorder differ greatly by gender. In addition, medical therapy must be tailored differently for men and women because of emerging safety concerns unique to the female reproductive system. In November 2005, these topics were explored by a panel of experts in psychiatry, neurology, and reproductive health at a closed roundtable meeting in Dallas, Texas. This clinical information monograph summarizes the highlights of that meeting.
Compared to men with bipolar disorder, women have more pervasive depressive symptoms and experience more major depressive episodes. They are also at higher risk for obesity and certain other medical and psychiatric comorbidities. Mood changes across the menstrual cycle are common, although the severity, timing, and type of changes are variable. Bipolar disorder is frequently associated with menstrual abnormalities and ovarian dysfunction, including polycystic ovarian syndrome. Although some cases of menstrual disturbance precede the treatment of bipolar disorder, it is possible that valproate and/or antipsychotic treatment may play a contributory role in young women.
Pregnancy does not protect against mood episodes in untreated women. Maintenance of euthymia during pregnancy is critical because relapse during this period strongly predicts a difficult postpartum course. Suspending therapy in the first months of pregnancy may be an option for some women with mild-to-moderate illness, or those with a long history of euthymia during pre-pregnancy treatment. However, a mood stabilizer should be reintroduced either in the later stages of pregnancy or in the immediate postpartum period. Preliminary data suggest that fetal exposure to some mood stabilizers may raise the risk of major congenital malformations and neurodevelopmental delays. For women planning to become pregnant, clinicians may consider switching to other drugs before conception. The value and drawbacks of breastfeeding during treatment must be considered in partnership with the patient, with close monitoring of nursing infants thereafter. The risks and benefits of medical treatment for women with bipolar disorder should be carefully reconsidered at each stage of their reproductive lives, with a flexible approach that is responsive to the changing needs of patients and their families.
Doctor Ellen Leibenluft explains that women and men are equally likely to develop bipolar disorder. Women are, however, more likely to develop the disorder after giving birth.
There are no gender differences in the prevalence of bipolar disorder. In other words, men and women are equally likely to have the illness. There is some evidence that women with bipolar disorder may tend to have particularly frequent depressions relative to men. There’s also some evidence, although it’s not entirely clearcut, that women may be more likely than men to have what’s called rapid cycling bipolar disorder, which means that they shift very rapidly between depression and mania. Importantly, women with bipolar disorder are at risk for having an episode when they are postpartum, so that’s a very important aspect of gender issues if you will and bipolar disorder. the postpartum period, right after a woman with bipolar disorder has a baby, she’s at very high risk to have an episode particularly actually of mania or mania mixed with depression.
This work by Cold Spring Harbor Laboratory is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.
Gender Differences in Incidence and Age at Onset of Mania and Bipolar Disorder Over a 35-Year Period in Camberwell, England
Gender differences in the epidemiology and course of schizophrenia are well established (1, 2). For instance, many studies have suggested that narrowly defined schizophrenia is more common in males and that the onset occurs earlier in male patients than in their female counterparts (3–5). Gender differences in bipolar affective disorder have also been described. Thus, women may have a higher risk of developing rapid-cycling bipolar disorder and dysphoric or mixed mania (6). Furthermore, women may be more likely to present with an initial depressive episode before onset of mania (7) and to suffer from a greater number of depressive episodes and from longer, more refractory episodes throughout the course of their illness (8, 9). However, whether there are gender differences in incidence or age at onset of bipolar disorder remains unclear.
Older studies found no consistent gender differences in age at onset of bipolar disorder (10), but some small, more recent cross-sectional studies that have used strict operational criteria for diagnosis suggested that women may have a later age at onset of mania and bipolar disorder (7, 11, 12). Higher incidence rates of mania in midlife have also been described (13), but studies of mania and bipolar disorder have generally been too small to provide reliable data regarding differences in incidence or age at onset by gender. Larger incidence studies could therefore examine gender differences in incidence of bipolar disorder throughout the lifespan, evaluate likely causative factors, and possibly identify subsets of bipolar disorder patients. Previous studies showed that age at onset of bipolar disorder is of critical importance, as early-onset bipolar disorder has been associated with more severe clinical symptoms (14, 15), comorbid substance abuse (16, 17), a stronger family history of affective disorder (18), and poor outcome (16, 17, 19). Furthermore, studies investigating distributions of age at onset identified subsets of bipolar disorder patients that may be differentiated on the basis of familial transmission and clinical symptoms (18, 20, 21). However, such studies were based on consecutive admissions or outpatient visits rather than on epidemiological samples, and thus they may be subject to referral bias. The current study, a 35-year incidence study of all psychiatric contacts (inpatient, outpatient, and community) with first-episode mania or bipolar disorder in southeast London, allowed us to investigate incidence rates and age at onset by gender in a large epidemiological sample.
We identified all cases of bipolar I disorder, first manic episode, in patients who contacted psychiatric services, including inpatient, outpatient, and community referrals, in a defined catchment area, Camberwell, southeast London, an inner-city area of approximately 120,000 people (London, Office of Population Censuses and Surveys, 1997), between January 1965 and December 1999. The identified cases included those involving patients whose first presentation to services was with mania and those involving patients who presented with a first manic episode after a previously assessed or treated depressive episode in primary or secondary care. This study was approved by the South-London and Maudsley Ethical Committee.
Identification of Cases
Clinical and sociodemographic data were collected for all people from the geographically defined area of Camberwell who presented with psychosis, mania, or hypomania between 1965 and 1999. All possible cases of mania, hypomania, schizophrenic psychosis, including the schizoaffective type, paraphrenia, and “other nonorganic psychosis” were extracted from the prospectively collected Camberwell Cumulative Psychiatric Case Register (22), which provided a comprehensive list of all persons from Camberwell who had their first contact with psychiatric services, including those not admitted, between 1965 and 1984.
From 1984 to 1999, cases were identified by generating a list from hospital computer records of all people admitted to any hospital serving the Camberwell catchment area who had any possible psychotic illness, mania, hypomania, or bipolar affective disorder, as coded by ICD-9 or ICD-10. In addition, case records of all patients from the area (1984–1999) were examined to identify those who had made contact with services but were not admitted. Patients admitted to hospitals outside the area would normally be transferred to local hospitals or services for continuing care, and these records were also identified.
To ensure that patients who initially presented to psychiatric services with major depression and later returned with mania were not missed by the Camberwell Case Register (1965–1984), which mainly recorded first contacts, we examined admission lists and ward reports for the entire follow-up period from all hospitals serving the Camberwell catchment area to identify patients with a diagnosis of mania or bipolar disorder. The compilation of this Camberwell database was previously described by Boydell et al. (23).
Patients who were not residents in the catchment area, had presented previously with a psychotic or manic episode, had a clear organic cause for their symptoms, or had onset before age 16 years were excluded from this study. Case records of the remaining subjects, including medical, nursing, social work, and occupational therapy notes, together with all correspondence relating to the case, were examined, and the Operational Checklist for Psychotic Disorders, Version 3.4 (24) was completed for each case by one experienced psychiatrist (N.K.) for the year after the patient’s presentation. The Operational Checklist for Psychotic Disorders is a well-validated symptom checklist that is based on the phenomenological descriptions in the Present State Examination (25). It has a glossary of clear and explicit descriptions for each constituent item of psychopathology and instructions for coding the items and was designed with case-note review in mind. Checklists prepared with this instrument were used to generate DSM-IV diagnoses by using the accompanying computer program. The patients who met the criteria for a DSM-IV diagnosis of bipolar I disorder, first manic episode, which included patients who experienced an episode of depression before onset of mania, were included in the analyses for this study.
Clinical and Sociodemographic Variables
Clinical and sociodemographic variables were extracted from case notes by an experienced psychiatrist (N.K.), who used a pro forma document, as described by Castle et al. (26). The age at onset of DSM-IV mania was defined according to Operational Checklist for Psychotic Disorders guidelines as the age at which first psychiatric contact was sought for mania. The age at onset of DSM-IV bipolar disorder was defined as the age at which treatment was first sought in primary or secondary care for any affective disorder, including major depression. Ethnicity was classified according to the ethnicity category stated by the patient. For analysis, ethnicity was divided into a white group (self-assigned ethnicity white) and a nonwhite group (all other self-assigned ethnicities). In the absence of a statement of self-assigned ethnicity, the patient’s and his or her parents’ place of birth, if available, and any description of color was used to determine ethnicity. Premorbid functioning in work and social areas and premorbid personality disorder were rated according to Operational Checklist for Psychotic Disorders criteria. Obstetric complications were rated according to the scale devised by Lewis and Murray (27), and family history of psychotic or affective disorder was rated according to Operational Checklist for Psychotic Disorders guidelines. Childhood antisocial traits or behavior were identified if the patient met the DSM-IV criteria for conduct disorder (persistent aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules). Childhood neurotic traits, antisocial traits, and juvenile delinquency were rated as described by Castle et al. (26). To assess interrater reliability for the variables described here, including age at onset of mania and bipolar affective disorder in 5-year bands, a random subset of 60 case notes was rated independently by another author (S.K.); results ranged between kappa 0.85 and 1.00 for different variables.
Incidence rates of DSM-IV bipolar I disorder, first manic episode, by gender were determined by 5-year age bands across the study period (1965–1999) by using data supplied from the Office for Population Censuses and Surveys. Population data concerning the general population of Camberwell were generated from the 1961, 1971, 1981, and 1991 censuses (100% samples) and were stratified by age and gender (London, Office for Population Censuses and Surveys and London Research Centre, 1997). Population estimates for the intermediate years were interpolated, and corrections were made for underenumeration throughout the entire time period. The male-female ratio of the general population of Camberwell remained fairly uniform throughout the period of study, with a slight female preponderance (London, Office for Population Censuses and Surveys, 1997).
Overall incidence rates and rate ratios by gender and age for 10-year age-at-onset bands were calculated by using the StATA statistical program (28). Mean differences in age at onset for first-episode mania and bipolar disorder by gender, family history, developmental variables, premorbid functioning, personality variables, and ethnicity were assessed with the Mann-Whitney U test because of the positive skew in the distribution of age at onset. Variables with significant or near-significant results were then entered into analysis of covariance (ANCOVA) with age at onset as the dependent variable. In this analysis, age at onset of mania and bipolar disorder were log transformed to remove skewness from the data. Associations between gender and individual premorbid variables were then sought by using chi-square tests.
Age at Onset by Gender
To examine whether differences in age at onset were consistent across the 35-year period of this study, gender differences in age at onset of first-episode mania or bipolar disorder were examined by using 5-year date bands. Age differences were consistently observed, with female patients having a later onset of mania and bipolar disorder during six of the seven date bands (mean difference=1.7–11.0 years) and male patients having a marginally later onset during one band.
Overall Incidence Rates for DSM-IV Bipolar I Disorder, First Manic Episode, by Gender
Figure 1 shows the incidence by 10-year age-at-onset bands for bipolar I disorder, first manic episode. The incidence for males peaked in the 16–25-year-old age group and fell dramatically in successive age bands, whereas the incidence was lower for females in the 16–25-year-old age group but did not fall as dramatically thereafter. Incidence was higher for females in all age bands, except for the 16–25 and ≥76 age bands (Table 1). Male-female rate ratios were <1 for each age band, with the exception of the youngest and eldest bands, although gender differences in incidence in the individual bands did not reach statistical significance.
Associations between selected premorbid psychosocial variables, including family history, developmental variables, premorbid functioning, personality and ethnicity, and age at onset of first-episode mania or bipolar disorder were sought 1) to ascertain whether any of these variables were associated with age at onset and 2) to identify whether they would influence gender differences in age at onset. As Table 2 shows, childhood antisocial traits or behavior and nonwhite ethnicity were associated with younger age at onset of mania; childhood antisocial traits were associated with age at onset of bipolar disorder, with juvenile delinquency and abnormal personality nearing statistical significance on these measures.
When the relationship between gender, ethnicity, and childhood antisocial behavior was investigated, male gender was found to be significantly associated with childhood antisocial behavior (χ2=5.46, df=1, p<0.02), although no other significant associations were found. No significant interactions between these three variables and age at onset of mania or bipolar disorder were identified.
We found a robust association between gender and age at onset of first-episode mania and bipolar disorder. Men had an earlier age at onset, even after adjustment for premorbid variables. In multivariate analysis, childhood antisocial behavior remained independently associated with earlier onset of mania and bipolar disorder, and nonwhite ethnicity remained independently associated with earlier onset of mania. Men also had a higher incidence of bipolar disorder in early adult life, and women had a higher incidence throughout the rest of adult life until late life, although these differences did not reach statistical significance for individual age bands.
The association of male gender and childhood antisocial behavior with early onset of bipolar disorder raises the possibility of a subgroup of early-onset, predominantly male bipolar disorder patients with behavioral difficulties. Antisocial behavior in childhood could be a manifestation of neurodevelopmental abnormality or even of early-onset bipolar disorder. The findings in this study were strikingly similar to those reported by Carlson et al. (16), who compared 23 early-onset (age <21 years) with 30 later-onset (age >30 years) patients with psychotic mania and found that early onset was associated with male gender and childhood behavioral difficulties. Other studies have also reported associations between early-onset bipolar disorder and neurodevelopmental or psychosocial impairment (29, 30). The higher incidence of bipolar disorder in men in early adult life, in contrast to the rest of adult life, in this study also supported a predominantly male early-onset subgroup. However, the interpretation must be made with caution, as only 10% of cases with an early onset (age <25 years) both reported childhood antisocial behavior and were male. By contrast, the association between nonwhite ethnicity and early-onset mania is likely to be due to younger age distributions in ethnic minority groups, compared with the white European population, over the course of this study.
Most of the older studies that investigated age at onset of bipolar disorder by gender found no significant differences between men and women, although a minority of studies found a later mean age at onset in women (10). More recent studies, which have used strict operational criteria for diagnosis, have mainly found a later onset of bipolar disorder in women (6). Thus, Viguera et al. (7), in a study of 360 outpatients with DSM-IV bipolar I disorder or bipolar II disorder, found that women were a mean of 3.2 years older at onset than men. Another study of 69 subjects mainly with bipolar I disorder found that women had significantly older age at onset of both depression and mania (11). Finally, a recent study of bipolar I disorder patients in the suburbs of London found that onset in women occurred a mean of 8.3 years later than in men (12). The current study showed that onset of bipolar disorder and mania in women occurred a mean of 4.4 years later and 5.1 years later, respectively, than in men; these results add weight to previous findings suggesting a gender difference in age at onset of bipolar disorder.
A number of studies have also shown that the onset of schizophrenia occurs approximately 4–5 years later in female patients than in male patients (4, 5, 26). However, incidence and age-at-onset distributions appear to be different in bipolar disorder and schizophrenia. In this study we found that women had a somewhat higher incidence of bipolar disorder throughout adult life, except in early life and late life. Similar findings have been described in national admission data (13, 31). By contrast, in schizophrenia, male patients predominate among those with an early onset, and a marked excess of female patients is found among those with an onset in late life (4, 26). The higher incidence of schizophrenia in early life among men, compared with women, has largely been explained by a greater likelihood that abnormal neurodevelopment affects men, because of later brain maturation, and by the protective effects of higher estrogen levels in women (32, 33). The high incidence in late life in women may in turn be related to the decrease in the level of estrogen during menopause (33). However, hormonal effects of estrogen are unlikely to have mainly accounted for the gender differences in onset of bipolar disorder observed in this study, as the incidence of bipolar disorder continued to decline even after menopausal age in women and the incidence of bipolar disorder remained higher in women than in men until late adult life.
Gender differences in age at onset of mania and bipolar disorder could also have been related to women’s seeking assessment or treatment later than men. One study has shown that women are more likely than men to have delays in receiving a prescription for maintenance treatment for bipolar disorder and in receiving a diagnosis of bipolar disorder (7). However, delays in assessment, particularly for mania, are less likely. Stressful life events that may differentially affect women, particularly pregnancy and the puerperium, have been associated with onset of mania (34). However, postpartum psychosis was unlikely to have contributed to the higher incidence among women in adult life in this study, as only five incident cases of first-episode mania occurred within 1 month of delivery and three of these cases were in the youngest age band, in which the incidence in males was higher. Similarly, other possible psychosocial factors such as unemployment or abnormal work or social functioning were not associated with either gender or age at onset of bipolar disorder in this study. Furthermore, gender differences in migration patterns were unlikely to have markedly influenced differences in age at onset, as gender differences in age at onset in nonwhite groups were less pronounced than in white Europeans. However, the influence of other social factors, which may particularly affect young men, including urban living, social deprivation, and alcohol or illicit drug abuse, cannot be discounted.
The main strengths of this study were that we identified all psychiatric contacts, not just contacts that resulted in admission or contacts involving cases of psychotic disorders, in an epidemiologically defined catchment area. Our sample was therefore representative of first-onset bipolar disorder, and our findings are more likely to be generalizable than are those of previous studies of age at onset. The design of the current study allowed us to estimate incidence rates of first-episode mania by age and gender, by using adjusted population data. Furthermore, the long time frame of this study allowed identification of a large number of incident cases, despite the relatively low incidence of bipolar I disorder in the general population. Diagnostic stringency was ensured by using computer-generated diagnoses. Finally, potentially confounding premorbid variables were considered.
The main limitation was the high proportion of missing case notes for the early years of the study. Almost 10% of the case notes for the first 10 years of the study period were missing, compared with less than 3% for the subsequent 25 years. However, if adjustment was made for missing notes in proportion to the number of cases examined, only approximately another 14 cases would have been detected, and the additional data would have been unlikely to affect the gender differences found in this study. This study was also confined to adult cases, as the original Camberwell Case Register identified only patients age 16 years or older at first contact. Therefore, the incidence of childhood-onset bipolar disorder in Camberwell could not be evaluated. Furthermore, over the long study period, the style or content of the case records may have changed, given the evolving nature of diagnosis and classification. However, in practice, case records compiled in the Bethlem and Maudsley Hospitals have used a standardized format that has varied little since the early 1970s (35).
Significant gender differences in age at onset of mania and bipolar disorder were observed in this study, and these differences persisted even after adjustment for potentially confounding variables. Furthermore, childhood antisocial behavior remained independently associated with early onset, raising the possibility of the existence of an early-onset bipolar subgroup.
These findings need replication in large-scale prospective epidemiological studies in which putative causal mechanisms could be further explored.
Received Jan. 7, 2004; revision received March 16, 2004; accepted April 6, 2004. From the Section of General Psychiatry, Division of Psychological Medicine, Institute of Psychiatry; the Department of Psychiatry, Addenbrooke’s Hospital, Cambridge, U.K.; and the Department of Psychiatry and Neuropsychology, South Limburg Health and Teaching Network, EURON, Maastricht University, Maastricht, the Netherlands. Address correspondence and reprint requests to Dr. Kennedy, Box 63, Section of General Psychiatry, Division of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, U.K.; (e-mail). Supported by a grant from the Stanley Medical Research Institute to Dr. Murray and a grant from the Psychiatry Research Trust to Dr. Kennedy. The authors thank Prof. David Castle, Prof. Simon Wessely, and Prof. Nori Takei for assistance with data collection.
Figure 1. Incidence of DSM-IV Bipolar I Disorder, First Manic Episode, by Age and Gender, in Patients Presenting to Treatment Services in Camberwell, England, 1965–1999
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Hospitalization, prevalent polarity, and female gender were found to increase the risk for rapid cycling in bipolar disorder, according to a study published in European Psychiatry based on data from the National Epidemiological Research on Bipolar Disorder (RENDiBi) project in Italy.
Researchers retrospectively studied cross-sectional data of 1675 patients (961 female) with a diagnosis of bipolar disorder. Data were collected from multiple Italian psychiatry clinics from April 2014 to March 2015 with the aim of comparing clinical and demographic characteristics of patients with and without rapid cycling. Chi-squared, Student’s t-test, and multivariate logistic regression analyses looked at several variables, including gender, education, history of hospitalizations, and prevalent polarity.
“A higher frequency of in women than men is one of the most replicated findings across studies about this topic,” the investigators noted.
One key limitation of the research was the retrospective nature of the study, as well as the varying settings of care.
“Patients require careful clinical monitoring to prevent recurrent hospitalization also in the light of a more frequently observed poor compliance,” the investigators concluded.
Buoli M, Cesana BM, Maina G, et al. Correlates of current rapid-cycling bipolar disorder: results from the Italian multicentric RENDiBi study. Eur Psychiatry. 2019;62:82-89.