Prevalence and burden of bipolar disorders in European countries

https://doi.org/10.1016/j.euroneuro.2005.04.011Get rights and content

Abstract

A literature search, supplemented by an expert survey and selected reanalyses of existing data from epidemiological studies was performed to determine the prevalence and associated burden of bipolar I and II disorder in EU countries. Only studies using established diagnostic instruments based on DSM-III-R or DSM-IV, or ICD-10 criteria were considered. Fourteen studies from a total of 10 countries were identified. The majority of studies reported 12-month estimates of approximately 1% (range 0.5–1.1%), with little evidence of a gender difference. The cumulative lifetime incidence (two prospective-longitudinal studies) is slightly higher (1.5–2%); and when the wider range of bipolar spectrum disorders is considered estimates increased to approximately 6%. Few studies have reported separate estimates for bipolar I and II disorders. Age of first onset of bipolar disorder is most frequently reported in late adolescence and early adulthood. A high degree of concurrent and sequential comorbidity with other mental disorders and physical illnesses is common. Most studies suggest equally high or even higher levels of impairments and disabilities of bipolar disorders as compared to major depression and schizophrenia. Few data are available on treatment and health care utilization.

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,

References (71)

  • B. Müller-Oerlinghausen et al.

    Bipolar disorder

    Lancet

    (2002)
  • J.P. Olié et al.

    Manic episodes: the direct cost of a three-month period following hospitalization

    Eur. Psychiatr.

    (2002)
  • A. Rossi et al.

    Personality disorders in bipolar and depressive disorders

    J. Affect. Disord.

    (2001)
  • M. Savino et al.

    Affective comorbidity in panic disorder: is there a bipolar connection?

    J. Affect. Disord.

    (1993)
  • P.J. Scully et al.

    Schizophrenia, schizoaffective and bipolar disorder within an epidemiologically complete, homogeneous population in rural Ireland: small area variation in rate

    Schizophr. Res.

    (2004)
  • G.E. Simon

    Social and economic burden of mood disorders

    Biol. Psychiatry

    (2003)
  • E. Szádóczky et al.

    The prevalence of major depressive and bipolar disorder in Hungary. Results from a national epidemiologic survey

    J. Affect. Disord.

    (1998)
  • M. Ten Have et al.

    Bipolar disorder in a general population in the Netherlands (prevalence, consequences and care utilization): results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

    J. Affect. Disord.

    (2002)
  • H.-U. Wittchen et al.

    Size and Burden of Mental Disorders in Europe—a critical review and appraisal of 27 studies

    Eur. Neuropsychopharmacol.

    (2005)
  • Z. Abood et al.

    Are patients with bipolar affective disorder socially disadvantaged? A comparison with a control group

    Bipolar Disord.

    (2002)
  • H.S. Akiskal

    The prevalence clinical spectrum of bipolar disorders: beyond DSM-IV

    J. Clin. Psychopharmacol.

    (1996)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • J. Angst

    Epidémiologie du spectre bipolaire

    Encéphale

    (1995)
  • J. Angst et al.

    Course of a clinical cohort of unipolar, bipolar and schizoaffective patients: Results of a prospective study from 1959 to 1985

    Schweiz. Arch. Neurol. Psychiatr.

    (1995)
  • J. Angst et al.

    Diagnostic issues in bipolar disorder

    Eur. Neuropsychopharmacol.

    (2003)
  • E. Baruffol et al.

    Anxiety, depression, somatization and alcohol abuse. Prevalence rates in a general Belgian community sample

    Acta Psychiatr. Belg.

    (1993)
  • P. Bebbington et al.

    The epidemiology of bipolar affective disorder

    Soc. Psychiatr. Epidemiol.

    (1995)
  • J. Biederman et al.

    Current concepts in the validity, diagnosis and treatment of paediatric bipolar disorder

    Int. J. Neuropsychopharmacol.

    (2003)
  • R.V. Bijl et al.

    Current and residual functional disability associated with psychopathology: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

    Psychol. Med.

    (2000)
  • R.V. Bijl et al.

    Psychiatric morbidity, service use, and need for care in the general population: results of the Netherlands Mental Health Survey and incidence study

    Am. J. Public Health

    (2000)
  • R.V. Bijl et al.

    The Netherlands Mental Health Survey and Incidence Study (NEMESIS): objectives and design

    Soc. Psychiatry Psychiatr. Epidemiol.

    (1998)
  • R.V. Bijl et al.

    Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

    Soc. Psychiatry Psychiatr. Epidemiol.

    (1998)
  • J. Canals et al.

    Prevalence of DSM-III-R and ICD-10 psychiatric disorders in a Spanish population of 18-year-olds

    Acta Psychiatr. Scand.

    (1997)
  • R. Das Gupta et al.

    Annual cost of bipolar disorder to UK society

    Br. J. Psychiatry

    (2002)
  • M. De Zelicourt et al.

    Frequency of hospitalisations and inpatient care costs of manic episodes: inpatients with bipolar I disorder in France

    PharmacoEconomics

    (2003)
  • Cited by (0)

    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).

    View full text