Research reportThe emerging epidemiology of hypomania and bipolar II disorder
Introduction
Since the introduction in 1980 of the American Psychiatric Association's Diagnostic and Statistical Manual DSM-III, most epidemiological studies on bipolar disorder have relied on DSM-III diagnostic criteria for mania and have been remarkably consistent in reporting low lifetime prevalence rates for bipolar I disorder (mania) of between 0.0 and 1.7%. Two examples are the Epidemiological Catchment Area Study of more than 18 000 subjects in the United States, which found a rate of 0.8% (Weissman et al., 1990), and the National Comorbidity Survey of the United States, which reported a rate of 1.6% (Kessler et al., 1994) (Table 1).
Low lifetime prevalence rates were also found in 11 studies conducted on bipolar II disorders, with figures varying between 0.5 and 1.9%, and one `outlier' of 3.0% (Table 2). Because hypomania is frequently not recognised by the probands, not reported and consequently not counted as a case, these findings must be considered as minimum rates.
Despite these low reported rates there is ample evidence to support the hypothesis that a wide bipolar spectrum exists in clinical samples (Akiskal, 1983, Akiskal and Mallya, 1987, Cassano et al., 1992) and occurs frequently in the community (Angst, 1995a, Angst, 1995b). This spectrum embraces mania, hypomania, recurrent brief hypomania, sporadic brief hypomania and cyclothymia. Five epidemiological studies have established lifetime prevalence rates for certain segments of the bipolar spectrum ranging from 3 to 6.5% (Table 3). Particularly significant in this context are the studies of children and adolescents which have identified rates of hypomanic and sub-threshold hypomanic syndromes of between 5.7 and 13.3% (Carlson and Kashani, 1988, Lewinsohn et al., 1995), findings which are concordant with the postulate of a high prevalence of the bipolar spectrum in adults.
In 1994 DSM-IV (APA, 1994) introduced new operational criteria for the diagnosis of hypomania, which included shorter manifestations: where the DSM-III definition required 1 week's duration, DSM-IV requires a minimum of 4 days. The Zurich Study has retrospectively applied the DSM-IV criteria for hypomania for the first time in an epidemiological study. The purpose of this paper is to demonstrate the high prevalence rates of hypomania in the community and the clinical relevance of the proposed new category, brief hypomania, with a duration of only 1–3 days. Preliminary results have been published elsewhere (Angst, 1995a, Angst, 1995b).
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Methodology
The data on hypomania were collected from the second to fifth interviews of the Zurich Cohort Study, which were conducted when the subjects were 22/23, 27/28, 29/30, 34/35 years of age (Angst, 1995a, Angst, 1995b). The sample itself is the result of a two-stage design, which selected subjects at high risk for psychiatric disorders and random controls from 4547 subjects drawn from the total population of the canton of Zurich at the ages of 19 (males) and 20 (females). Screening took place in
Prevalence rates and symptomatology
Table 5 shows the frequencies and weighted lifetime prevalence rates of hypomanic manifestations. DSM-IV hypomania (including mania) was found in 5.5% of the population, recurrent brief hypomania in 1.5%, sporadic brief hypomania in 1.3%; a further 11.3% of the population manifested subdiagnostic hypomanic symptoms. Table 4 shows the 15 items characterising hypomania, deliberately worded positively so that they would be readily acceptable to probands. The symptom profiles (Fig. 1) from the last
Validity of hypomanic syndromes
Table 6 provides data on clinical validity. The highest rate of a positive family history for hypomania was found in cases meeting DSM-IV criteria (21.1%), but the other groups, including `hypomanic symptoms only', also showed a 2-fold higher risk of hypomania among family members compared to controls (4.6%). A positive family history of depression occurred significantly more frequently in the hypomanic subgroups than in controls, but not when it came to family history of treatment for
Consequences of hypomania
The risk of developing substance abuse was clearly elevated among hypomanics. The same was true for tobacco dependence and alcohol abuse/dependence as shown in Table 6; indeed abuse of tobacco and alcohol was more frequent among hypomanics than among depressives and controls. A similar trend was found for the regular consumption (at least weekly over 1 year) of cannabis and minor tranquillisers. There was also a trend towards elevated binge-eating rates among hypomanics compared to depressives.
Comorbidity
Significant associations were found between all subgroups of hypomania and DSM-III anxiety disorders. But, while there was no association between DSM-IV hypomania and any subtype of phobia (agoraphobia, social or simple phobia) (Table 6), the association of brief hypomania with social phobia was almost three times higher than among the controls. DSM-III panic disorder and repeated panic attacks were 10-fold more frequent among all subgroups of hypomania than among controls. OCD and
Discussion
There is growing evidence for the existence of a broad spectrum of hypomanic/manic syndromes with a high prevalence and various forms of associations, simultaneous or subsequent, with the spectrum of depression. The spectrum concept of hypomania can be traced back to Kraepelin's postulate (Kraepelin, 1913) that subjects with `manic' and cyclothymic temperaments belong to the manic-depressive group, embracing a continuum from normal temperament to full-blown affective psychosis. This position
Acknowledgements
Supported by Grant 32-33580.92 from the Swiss National Science Foundation.
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