There are several studies about the effect of gender differences on clinical presentation of bipolar disorder (BPD). Research provided information particularly about prevalence, age of onset, treatment adherence, disease course and clinical symptom domains of the disease (1).
Epidemiological studies about BPD showed that lifetime prevalence of a manic episode is 1.7% in women and 1.8% in men and age of onset is similar between genders (2,3). It was reported that disease often starts with a manic episode in men and with a depressive episode in women (4,5). Although women reported to experience higher number and more frequent depressive episodes (4) and reported to have more cycles and mixed episodes (6-9), there are studies showing that these frequencies resemble at both genders (3,10,11).
Clinical symptoms are reported to be similar at both men and women in a study (7). It was reported that age of onset is smaller in men than women in cases whom psychotic symptoms accompany manic episodes and women were reported to have higher Young mania scores, have more depressive episodes and age of onset is smaller than men (12,13).
Psychosocial functionality was reported to vary between genders in BPD (14,15). It was reported that there is no difference between genders for stigmatization but social relation quality is better in women. In a similar study, it was found that women are more successful in conducting interpersonal relations but occupational and social functionality levels are similar between genders (1).
Abovementioned studies make it possible to perform a general evaluation about the relationship between BPD and gender. However, it was generally not detailed what differences patients with BPD show during a certain episode of the disease. Several clinical and socio-demographic differences which may be related with gender can be predicted particularly at the manic episode. In this study, we aimed to evaluate all clinical and socio-demographic characteristics thought to be related with gender and bring up whether there are differences for gender in manic episode of BPD.
A hundred male and 100 female patients who were consecutively hospitalized to women’s and men’s inpatient departments of Erenköy Training and Research Hospital for Mental Health and Diseases between February and December 2010 and diagnosed as “BPD last episode mania” according to DSM-IV criteria, meeting inclusion-exclusion criteria of the study, accepted to sign the consent form after he/she or relatives of patients were informed about the study and was able to adapt interview.
Inclusion criteria of the study were as follows:
1- Patients with manic episode of BPD according to DSM IV criteria,
2- Patients between the ages of 18 and 65 years,
3- Severe episodes requiring hospitalization
Exclusion criteria of the study were as follows:
1- Patients younger than the age of 18 and older than the age of 65,
2- History of a comorbid Axis I psychiatric disorder or mental retardation,
3- History of alcohol/substance abuse or dependence,
4- Conditions hindering communication such as deafness etc.
Assessment Tools and Administration
Study was started after taking approval from Ethical Committee of Erenköy Training and Research Hospital for Mental Health and Diseases. After patients were diagnosed according to DSM-IV criteria (16), they were informed accordingly and recruitment was done after consent of patient or legal guardian was obtained. All patients were administered “Socio-demographic Data Collection Form” prepared by our team, “Brief Psychiatric Rating Scale”, “Young Mania Rating Scale” and “Bipolar Functionality Scale”. “Sleep, Libido and Eating Behavior List” which was formed by our team using some items of Bech Rafaelson Mania Scale was also administered. When patients whom were followed-up after these tests were discharged, types of treatment and durations of hospital stay were determined.
Socio-demographic Data Collection Form: This form was prepared by authors to evaluate demographical and clinical variables such as age, marital status, educational background, profession, history of psychiatric disease, age of onset of disease, age of first treatment, first episode of disease, presence of a life event triggering the disease, total number of episodes, number of hospitalizations and mean duration of hospitalization during an episode.
Brief Psychiatric Rating Scale (BPRS): This scale was developed by Overall and Gorham (17) and used to assess the severity of psychotic and some depressive symptoms. It is a seven-point Likert-type scale consisting of 18 items. In the original version which scoring was done between 0 and 6, scores between 15 and 30 indicate minor and scores over 30 indicate major syndrome. Lowest score is 0 and highest possible score is 108. It is recommended to be used in comparative studies due to absence of a cut-off score. It was translated to Turkish. In our study, scores received from each scale item and total score were compared according to gender.
Young Mania Rating Scale (YMRS): This scale was developed by Young et al. (18) and used to assess the severity of manic attack. Seven items of the 11-item scale is five-point Likert-type and remaining four items are nine-point Likert-type. Lowest possible score is 0 and highest possible score is 44. Validity and reliability of the Turkish version was done (19). Cut-off point was not calculated in the study of Turkish version. In our study, both scores from each item and total scores of the scale were compared according to gender.
Functionality Scale in Bipolar Disorder (FSBD): This scale is a 52-item, self-rating scale used to assess functionality levels of patients with BPD at active episodes or at recovery intervals. It was developed by Aydemir et al. (15). It consists of 11 sub-scales of emotional functionality, mental functionality, sexual functionality, stigmatization, social withdrawal, in-house relations, relations with friends, participation to social activities, daily activities and hobbies, taking initiatives and ability to use the potential and job/occupation. This scale is recommended to be utilized in comparative studies due to lack of cut-off scores.
Sleep, Libido and Eating Behavior List: As already known, 9th item of Bech Rafaelson Mania Scale (20) consists of “duration of sleep reduced by 25%”, “duration of sleep reduced by 50%”, “duration of sleep reduced by 75%” and “no sleep” options. We added a fifth option to these as “not need to sleep” and formed the item evaluating sleep behavior. Scores between 1 and 6 can be achieved from these options. Also, item evaluating libido was formed by using options from 10th item of Bech Rafaelson Mania Scale such as “Habitual sexual interest and activity”, “slight increase in sexual interest and activity”, “moderate increase in sexual interest and activity”, “marked increase in sexual interest and activity” and “completely and inadequately occupied by sexuality”. Scores between 1 and 5 can be achieved from options. Item evaluating eating behavior was designed by authors. For appetite, it was designed to score between 1 and 5 to “absent”, “somehow decreased”, “normal”, “mildly increased” and “very much increased” options. “Sleep, Libido and Eating Behavior List” was formed and achieved scores were compared according to gender.
Statistical analyses were performed by SPSS v16.0 software. For statistical analysis, t-test was used to compare numerical values between men and women including parametric assumptions such as age, clinical variables and functionality scale. Socio-demographic variables were compared by using chi-square test. ANOVA test was used to compare clinical variables between groups according to marital status. Paired group origin of numerical variables found to be significant by ANOVA test was determined by Post-hoc Tukey HSD test. Relationship between clinical variables was calculated by Pearson correlation analysis. Numerical variables were represented as mean ± standard deviation. Statistical significance was taken as p<0.05.
Age (p=0.92), educational level (p=0.65), history of a psychiatric disease in relatives (p=0.34), age of onset of disease (p=0.71), first age of treatment (p=0.89), total number of episodes (p=0.19), total number of hospitalizations (p=0.31) and mean duration of hospital stay (p=0.97) of female (n=100) and male (n=100) patients participated in the study were found similar. No significant difference was found between groups for number of total manic (p=0.16), mixed (p=0.06) and depressive (p=0.80) episodes; however, marital status (p<0.01), working status (p<0.01) and first episode type (p=0.03) was found significantly different. Frequency of a life event triggering the episode was found significantly higher in women than men (p<0.01) (Table 1).
No correlation was found between groups for sleep (p=0.95) and eating behavior (p=0.75) scores but libido scores were found significantly higher in men (p<0.01). BPRS scores were found similar between groups (p=0.73). Total YMRS scores were found similar between groups (p=0.10); however, when scores from scale items were compared separately, scores of the third item evaluating increase in sexual desire were found significantly higher in men (p<0.01) (Table 2).
No significant difference was found between emotional functionality (p=0.29), mental functionality (p=0.70), relations with friends (p=0.059), daily activities and hobbies (p=0.75), initiative taking and ability to use potential (p=0.09) scores from BPSD. Scores achieved from sexual functionality (p<0.01), participation at social activities (p<0.01), occupation (p<0.01) stigmatization (p<0.01) domains were found significantly higher in men and scores achieved from in-house relations (p=<0.01) and social withdrawal (p<0.01) domains were found significantly higher in women (Table 2).
No statistically significant difference was found between duration of inpatient treatment (p=0.44) and Electroconvulsive Therapy(ECT) administration rates (p=0.62) of men and women.
Relationship between age, age of onset, initial age of treatment, total number of episodes, total number of manic, mixed, hypomanic and depressive episodes, total number of hospitalizations, mean durations of hospital stay, sleep, eating and libido behavioral scores, single and total scores of YMRS items, total scores of BPRS and sub-scale scores of FSBD of patients were examined. Positive linear correlation was found in men between total number of episodes and total number of depressive episodes (r=0.49, p<0.01), total number of manic episodes and mean duration of hospital stay (r=0.28, p<0.01), initial age of treatment and social withdrawal scores (r=0.25, p<0.01); negative linear correlation was found in men between age and participation at social activities (r= -0.21, p=0.02), daily activities and hobbies (r=-0.20, p=0.03), initiative taking and ability to use potential (r=-0.26, p<0.01), age of onset and mental functionality (r=-0.31, p<0.01), initial age of treatment and mental functionality (r=-0.29, p<0.01), total number of hospitalizations and participation at social activities (r=-0.20, p=0.04), mean duration of hospital stay and relations with friends (r=-0.19, p=0.05) and participation at social activities (r=-0.32, p<0.01) scores. In women, positive linear correlation was found between age and 4th item of YMRS evaluating insomnia (r=0.28, p=0.01), age of onset and daily activities and hobbies (r=0.22, p=0.02), total number of episodes and sleep behavior (r=0.19, p=0.05), 4th and 10th items of YMRS (r=0.30, p<0.01), total number of manic episodes and sleep behavior (r=0.25, p<0.01), 4th item of YMRS evaluating insomnia and 5th item evaluating irritability (r=0.34, p<0.01), (r=0.20, p=0.04) and 10th item (r=0.23, p=0.02), total number of hospitalizations and 4th item of YMRS (r=0.35, p<0.01); negative linear correlation was found between age of onset of disease and total number of depressive episodes (r=-0.20, p=0.04), total number of hospitalizations (r=-0.21, p=0.03), stigmatization (r=-0.29, p<0.01), total number of episodes and daily activities and hobbies (r=-0.28, p<0.01), total number of manic episodes and sexual functionality (r=-0.26, p<0.01), relations with friends (r=-0.20, p=0.04), participation at social activities (r=-0.21, p=0.03), daily activities and hobbies (r=-0.25, p<0.01), total number of hospitalizations and daily activities and hobbies (r=-0.24, p=0.01), mean duration of hospital stay and 9th item of YMRS evaluating destructive-hostile behavior (r=-0.21, p=0.02).
Age of onset of disease, initial age of treatment, initial type of episode, total number of manic, mixed, hypomanic and depressive episodes, total number of hospitalizations, mean durations of hospital stay, sub-scale variables of functionality scale were shown at Table 3. Significant correlations were found between marital status and number total hospitalizations (p<0.01), stigmatization (p=0.02), social withdrawal (p=0.04) and relations with friends (p=0.03) in men compared to women; significant correlations were found between sexual functionality (p=0.02), participation at social activities (p=0.04), initiative-taking ability to use potential (p=0.04) scores in women compared to men (Table 3).
Age of disease onset was found similar between groups. This finding supports finding of Kawa et al. but not Kennedy et al. whom found an earlier age of onset in men (4,5). This may suggest that disease has neurodevelopmental mechanisms similar to gender. Presence of a triggering life event was found higher in women than men. This finding might have been due to encountering more traumatic life events by women or being more affected than men from events experienced. This issue should be further and in-depth investigated according to characteristic of the life event.
Married cases were found more among women and singles were found more among men. When women having significantly higher scores at in-house relations sub-scale and functionality scale were evaluated together, women with BPD might have been affected from disease less than men about marrying and maintaining marriage. Effect of disease on marriage or role of cultural factors on marriage status of patients from both gender are not known. We evaluated this relationship with regard to the effect of marital status on other variables as well. In a study which role of gender on married and single patients with BPD, it was found that age of onset is earlier in single men and married women experience less depressive episodes (21). We found that onset of disease is earlier in single cases of both gender and there is no correlation between number of depressive episodes and marital status. Number of total and manic episodes was found higher in widows of both genders. It was found that number of hospitalizations was higher in male widows, feeling of stigmatization was lower and relations with friends were higher in married men and social withdrawal was found lower in single men. Participation at social activities was found lower in married women and sexual functionality was found lower in single women. It can be proposed by these findings that social support of marriage may have a protective role for both genders for early onset of disease and total number of episodes. Marriage seems to affect social activities positively in men but negatively in women. This might have been due to determining roles of various cultural factors of genders on family institution.
Higher proportion of unemployment in women than men was supported by lower functionality scores in business life. This finding is not consistent with findings of Miquel et al. (1) who found that occupational functionality is similar between genders. This condition may be related with involvement of women predominantly with homework and family and involvement of men predominantly with financial issues.
We found that mania was more prevalent as the first episode in men than women similar to Miquel et al. (1). Moreover, total number of episodes and types of these episodes were found similar. This finding does not support the notion of “manic episodes are more frequent in women and depressive episodes are more frequent in men” (22). When current different findings were evaluated together, it can be suggested that biological mechanism which determines type and course of onset of disease and episode types is not affected by gender. Further biological findings are needed in order to reach definite judgments.
Mean duration of hospitalizations at episodes were found similar in both genders. This finding does not support the finding of Kessing (11) who found longer duration of hospitalization in women. This finding may suggest that biological and psychosocial factors affecting treatment response and recovery processes do not differ between genders.
Severity of manic symptoms did not significantly differ between genders. This finding is consistent with the literature (1,4). When YMRS items were examined separately, “sexual interest” score was found higher in men. Finding higher scores and behaviors of “sexual functionality” at item assessing libido in BPSD in men is consistent with this finding. High levels of sexual desire in men are not affected by age but decreases by age in women. Moreover, sexual functionality level of men was not affected by marital status but was lower in single women than married and widowed women. This finding may be due to longer maintenance and being less affected by social factors of sexuality in men but culturally inappropriateness of sexual activity of women.
Men scored higher than women at “participation in social activities” item of BPSD. This finding does not support the finding of Miquel et al. (1) who found similar social functionality at both genders. This may be due to lower level of participation of women in social activities in our society.
It was found that item 4 scores of YMRS which assessed insomnia in women were linearly correlated with age, total number of episodes, total number of manic episodes and total number of hospitalizations. Similarly, it was reported in the literature that severity of mania and depression increase by decreasing amount of sleep (23,24). It can be said that this finding was predictable when both negative effects of psychiatric disorders on sleep architecture and contribution of impairment sleep architecture on psychopathological condition.
A linear correlation was found between age of onset of disease and initial age of treatment and decreases mental functionality in men. The reason of decreased mental functionality which seemed to be related with men is not clear. Generally, cognitive impairment is observed at all types of episodes including euthymic episodes in patients with BPD (25). However, there is not sufficient data which indicate cognitive impairment differs between genders. It can be proposed that it is not clear to what extent mental activity we assessed reflect changes in cognitive activity and factors such as active participation at social or occupational lives which may require higher level of utilization of mental capacities and functions might have affected these findings. For this reason, this subject needs to be further evaluated in detail.
There are gender-specific differences among BPD patients at manic episode in domains such as socio-demographic characteristics, clinical symptoms, disease severity and functionality. Some of them might have been due to biological and others might have been due to cultural factors. Evaluating patients at manic episode by considering gender-specific differences may increase patient compliance. Most important limitations of this study are inadequate information obtained due to being at manic episode and relatively narrower sample size. It can be said that further studies without these limitations may contribute to better understanding of gender-specific factors.
In this study which compared socio-demographic and clinical characteristics of patients at manic episode of BPD, main findings of differences between genders were as follows:
1- Functionality scores evaluating marriage rates and in-house relations were found higher in women.
2- Employment rates and occupational functionality scores were found higher in men.
3- Presence of a premorbid life event was found more frequent in women.
4- Libido, increase in sexual desire assessed by item 3 of YMRS and sexual activity scores were found higher in men. Sexual desire decreases by age in women but does not change in men.
5- There is a correlation between age of onset and decreased mental functionality in men.
6- Marriage is related with participation in social activities and initiative-taking and using potential sub-scores in women and lower stigmatization sub-scores in men.
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