Unipolar mania reconsidered evidence from a South African study

Abstract

Objective: There is a lack of studies that examine prevalence and phenomenology of bipolar disorder in Africa. In literature, a unipolar manic course of illness in particular is reported to be rare. The purpose of this study was to investigate and describe the course of illness and clinical features for a cross-section of patients diagnosed with bipolar disorder attending public hospitals in Limpopo Province, South Africa and to determine the rate of a unipolar manic course in this sample of patients. Method: This was a descriptive, cross-sectional study of patients presenting with a history of mania between October 2009 and April 2010, to three hospitals in Limpopo Province. A purposeful sample of 103 patients was recruited and interviewed using the Affective Disorders Evaluation. Results: This study confirms that a unipolar manic course is indeed much more common than occurrences suggested in present day literature, with 57% of the study sample ever experiencing manic episodes. Patients presenting with a unipolar manic course of illness, as described in this study, may contribute to the search for an etiologically homogeneous sub-group, which presents a unique phenotype for genetic research and the search for genetic markers in mental illness. With a view to future research, a unipolar manic course therefore needs to be considered as a specifier in diagnostic systems in order to increase the awareness of such a course of illness in bipolar disorder. Conclusion: Fifty seven percent (57%) of study subjects had only ever experienced manic episodes, which is in keeping with findings from Africa and other non-Western countries. Identifying etiologically homogenous subgroups in psychiatry can also aid the profession in developing a reliable and valid nosology for psychiatric disorders. We need to consider a unipolar manic course at least a specifier in DSM and ICD.

Characterization of clinical features and comorbidities between bipolar affective disorder with and without depressive episodes

“…A meta-analysis from nine community samples indicated that UM patients are more likely to have comorbid drug use disorder than D-M patients (Angst et al, 2019). However, other studies have found that this is only true for amphetamine and cannabis abuse (Grobler et al, 2014;Pfohl et al, 1982). Contrary to previous research, we found a higher proportion of substance use disorder in the D-M group, both in the GREAT and PIMC cohorts, including smoking, alcohol use, and drug use.…”

“…This was to be expected as suicidal behaviors are more likely to present in patients experiencing depression (Miller & Black, 2020 ). These results are in agreement with those found in other longitudinal studies and review articles that have demonstrated a distinct clinical profile for UM patients (Amamou et al, 2018 ; Angst et al, 2019 ; Grobler et al, 2014 ; Mehta, 2014 ; Yazıcı, 2014 ).…”

“…In most longitudinal studies, if the follow-up period was more than 5 years, the proportion of UM was lower than 15% (Angst, Gerber-Werder, Zuberbühler, & Gamma, 2004 ; Solomon et al, 2003 ; Stokes et al, 2020 ). Additionally, the reported proportion of UM has tended to be higher in non-Western countries, with averages of 40.8% v. 16.8% (Grobler, Roos, & Bekker, 2014 ). There have been few studies of UM among the Asian population.…”

“…Concerning clinical characteristics, patients with UM have been reported to have an earlier age of onset (Angst & Grobler, 2015 ; Yazıcı, 2014 ), more psychotic features (Grobler et al, 2014 ; Pfohl, Vasquez, & Nasrallan, 1982 ; Yazici et al, 2002 ), more cannabis abuse (Grobler et al, 2014 ; Pfohl et al, 1982 ), fewer suicide attempts (Angst et al, 2004 , 2019 ), shorter sleep duration and an excessively hyperthymic temperament, a greater tendency to an early chronotype (morningness) (Angst & Grobler, 2015 ), and less comorbidity with anxiety disorders (Angst et al, 2019 ) compared with patients with D-M. These early observations were mainly obtained from clinical samples of European descent with relatively small sample sizes.…”