Prevalence and burden of bipolar disorders in European countries☆
Introduction
Bipolar disorder (previously also labeled manic-depressive illness) is typically referred to as an episodic, yet lifelong and clinically severe affective (or mood) disorder. Bipolar disorder, associated with considerable treatment needs, is associated with tremendous social and occupational burden for both the individual and family in a substantial percentage of cases (Abood et al., 2002, Bebbington and Ramana, 1995, Bijl and Ravelli, 2000a, Bijl and Ravelli, 2000b, Fichter et al., 1995, Simon, 2003, Wittchen et al., 2003, Woods, 2000). The term bipolar disorder, however, encompasses several phenotypes of mood disorders, i.e. mania, hypomania or cyclothymia that may present with a puzzling variety of other symptoms and disorders. According to the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994), the diagnostic classificatory system used in most epidemiological studies, bipolar disorder is defined by a set of specific symptom criteria. Bipolar type I requires the presence or the history of at least one manic or mixed episode. Although, typically, patients with a manic episode also experience major depressive episodes, bipolar disorder can be diagnosed even if only one manic episode and no past major depressive episodes are present. Bipolar disorder type II differs form type I only by presence of hypomanic but no manic episodes. Hypomanic episodes differ from mania by a shorter duration (at least 4 days instead of 1 week), and less severe impairment (not severe enough to cause marked impairment in social or occupational functioning, psychiatric hospitalization, or psychotic features). The DSM-IV also includes ‘cyclothymia’ as a bipolar spectrum disorder with hypomanic as well as depressive episodes that do not meet criteria for major depression (APA, 1994). More recently, some authors have suggested extending bipolar criteria in various ways. For instance, expanding the diagnosis to include childhood conditions despite different symptom presentations (Biederman et al., 2003), relaxing duration criteria to include subthreshold manifestations (Angst, 1998, Angst et al., 2003a, Angst et al., 2003b), and more generally by including a wider scope of bipolar spectrum disorders (Akiskal, 1996).
Aside from these conceptual considerations, the primary aim of this paper is to review epidemiological surveys in the community that provide data on bipolar disorder I and II in Europe, focusing on identifying similarities and differences of the prevalence rates from various studies. Further, available information on age of onset, comorbidity with physical and mental disorders, and burden associated with bipolar disorders will be reviewed.
Section snippets
Methods
Studies referenced in Medline, EMBASE and Psycho Info and published after 1980 were included in this review. For details regarding the search process see Wittchen and Jacobi (2005). Only studies meeting the following criteria were included: (i) use of structured or standardized diagnostic interviews, (ii) use of diagnostic criteria for bipolar disorder according to ICD-10 (1992) or the APA (1994), (iii) data published in either English, German, French, Italian, Portuguese, or Spanish language,
Prevalence and incidence
Table 1 displays the findings from a total of 14 studies in 10 EU countries meeting the inclusion criteria. All studies are general population samples. Age ranges covered were quite variable, ranging from birth cohort studies of subjects aged 55–57, over studies in 14–24 years olds, to studies covering a wider age range. The majority of studies included are regional surveys, with the exception of four studies. Five are based on small sample sizes of less than 1.000 subjects. The majority of
Prevalence
The epidemiology of bipolar disorders in Europe has been described in several studies with a remarkable degree of consistency across diverse study designs and countries. The evidence from community studies is highlighted by the clinical description of bipolar disorder as an episodic disorder that usually emerges in early adulthood, with a mean age of onset estimated to be between age 20 and 30. There is fairly convergent evidence that bipolar I and II disorders, according to DSM-IV criteria,
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This paper was prepared in the framework of European College of Neuropsychopharmacology (ECNP) Task Force project on “Size and Burden of Mental Disorders in Europe” (PI: Hans-Ulrich Wittchen). The paper also serves as input for the European Brain Council (EBC; www.ebc-eurobrain.net) Initiative “Cost of Disorders of the Brain” (Steering committee: Jes Olesen, Bengt Jönsson, Hans-Ulrich Wittchen).