Unipolar Mania: Recent Updates and Review of the Literature

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Psychiatry J. 2014; 2014: 261943.
Published online 2014 Apr 30. doi:  [ 10.1155/2014/261943 ]
PMCID: PMC4020165
PMID: 24877052

Unipolar Mania: Recent Updates and Review of the Literature

Shubham Mehta *

Shubham Mehta

Department of Psychiatry, SMS Medical College, Jaipur Rajasthan 302004, India

Find articles by Shubham Mehta
Author information Article notes Copyright and License information Disclaimer
Department of Psychiatry, SMS Medical College, Jaipur Rajasthan 302004, India
*Shubham Mehta: [email protected]
Academic Editor: Claude Robert Cloninger
Received 2014 Jan 1; Revised 2014 Apr 11; Accepted 2014 Apr 16.
Copyright © 2014 Shubham Mehta.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction. Unipolar mania (UM) has received less than the expected attention, when compared to its contemporary mood disorders, unipolar depression (UD) and bipolar disorder (BD). Method. The literature search included PUBMED and PSYCINFO databases. Cross-searches of key references were made to identify other articles of importance. Results. There seems to be a bipolar subgroup with a stable, unipolar recurrent manic course. Although UM does not have significant differences from bipolar mania in terms of sociodemographic variables, there are certain significant differences in clinical features. UM is reported to have more grandiosity, psychotic symptoms, and premorbid hyperthymic temperament, but less rapid cycling, suicidality, seasonality, and comorbid anxiety disorders. It seems to have a better course of illness with better social and professional adjustment. However, its response to lithium prophylaxis is found to be poor as compared to classical BD and valproate could be a better choice in this case. Conclusion. The available literature suggests that UM has certain differences from classical BD. The evidence, however, is insufficient to categorize it as separate diagnostic entity. However, considering UM as a course specifier of BD would be a reasonable step.

1. Introduction: Unipolar Mania—Then and Now

“Periodic mania” was the term which was first used by Kraepelin (1899) to refer to some of his cases having recurrent manic episodes without depression [ 1 ]. Wernicke (1900) proposed that single or recurrent episodes of mania or depression should be viewed as distinct disorders [ 2 ], separate from the ones which follow the continuous circular course of depression, mania, and free interval or “folie circulaire” as proposed by Falret [ 3 ]. “Phasic psychoses” were then classified by Kleist (1911, 1953) [ 4 , 5 ] and Leonhard (1957) [ 6 ] who labeled pure mania and pure melancholia as “pure phasic psychoses” and manic-depressive psychosis as a “polymorphous phasic psychosis.” Genetic basis for distinction between unipolar mania and manic-depressive psychosis was first suggested by Neele (1949) [ 7 ].

The evolution of unipolar mania (UM) has continued since then, despite not receiving the distinct nosological status in the two most commonly used and accepted classificatory systems of DSM and ICD.

It did not find any place even in the recently introduced DSM-5 [ 8 ]. In the chapter of bipolar and related disorders, DSM-5 has clearly stated that the lifetime experience of major depressive episode is not a requirement for diagnosing bipolar I disorder. This implies that the isolated and recurrent episodes of mania also would fall into the category of bipolar I disorder.

ICD-10, however, has included “recurrent mania NOS” along with bipolar II disorder into the category of “other bipolar affective disorders” [ 9 ].

Thus, UM has received less expected attention than its contemporary mood disorders, unipolar depression (UD) and bipolar disorder (BD). Anyhow, it still manages to sparkle the nosological debate amongst researchers every now and then because there are a sufficient number of patients, reported from several countries and cultures, who demonstrate a recurrent unipolar manic course.

The paper reviews the available literature on unipolar mania. This would be of help to address the question that “whether unipolar mania stands apart as distinct nosological entity or not.” This also would serve to identify the gaps in the literature regarding UM which can guide the future research in this area.

2. Search Methodology

This update is based on the literature search carried out by the author. The literature search included PUBMED and PSYCINFO databases using the following keywords (in different combinations): “unipolar mania, recurrent mania, recurrent unipolar mania, periodic mania, and pure mania.” Cross-searches of key references were made to identify other articles of importance. No publication year limits were applied. The titles and abstracts were examined manually, and full-text articles of potentially relevant studies were obtained.

The available literature has been organized under the headings of prevalence, sociodemographic correlates, clinical features, laboratory investigations, and treatment issues and is discussed in comparison to bipolar mania at most places. Finally, the important findings are summarized and conclusions are made.

3. Prevalence

The prevalence of UM has ranged widely from as low as 1.1% [ 10 ] to as high as 65.3% [ 11 ] mainly because different defining criteria have been used by different researchers.

Perris in 1966 defined unipolar mania as “one or more manic episodes with no depressive episode” and found the prevalence of UM to be 4.5% among all bipolar patients [ 12 ]. This definition was continued to be used in most of the studies [ 10 , 13 – 17 ] in 1970s and early 1980s which used retrospective chart reviews for their analysis. The prevalence of unipolar mania with this definition thus ranged from 1.1% of all bipolar patients [ 10 ] to 35.2% of bipolar inpatients [ 15 ]. Nurnberger et al. (1979), however, defined UM as minimum 1 hospitalization for manic episode and no hospitalization or somatic treatment for depression and found 15.7% of bipolar I disorder patients to be unipolar maniacs [ 18 ]. The retrospective studies which analyzed the prevalence of UM are shown in Table 1(a) .

Table 1

(a) Retrospective studies related to prevalence of UM. (b) Prospective studies related to prevalence of UM.

(a)

Author (year)PrevalenceDefinition
Perris (1966) [ 12 ]4.5% among all BD patientsM ≥ 1, D = 0

Abrams and Taylor (1974) [ 13 ]28% of BD I patientsM-number not defined, D = 0

Nurnberger et al. (1979) [ 18 ]15.7% of BD I patientsM ≥ 1 hospitalization, D = no hospitalization or somatic treatment

Abrams et al. (1979) [ 14 ]18% of BD patientsM ≥ 2, D = 0

Perris (1982) [ 10 ]1.1% of BD patientsM ≥ 1, D = 0

Pfohl et al. (1982) [ 15 ]35.2% of hospitalized BD patientsM ≥ 1, D = 0

Rao et al. (1982) [ 16 ]2.7% of lithium clinic patientsOnly M during follow-up, D = 0

Venkoba Rao and Madhavan (1983) [ 17 ]12% of BD patients
(age of onset >60 years)
Only M during follow-up, D = 0

Srinivasan et al. (1982) [ 19 ]40% of hospitalized BD patientsM ≥ 3, D = 0

Margoob and Dutta (1988) [ 40 ]42% of all BD patientsM = not defined, D = not defined

Khanna et al. (1992) [ 20 ]44% of hospitalized BD patientsM ≥ 4, D = 0

Avasthi et al. (1996) [ 21 ]6.45% of all affective disordersM ≥ 3, D = 0

Aghanwa (2001) [ 22 ]47.2% of all BD patientsM ≥ 3 (includes hypomania as well) and affective illness for at least 4 years, D = 0

Yazici et al. (2002) [ 23 ]16.3% of BD I patientsM ≥ 4 and at least 4 years of follow-up, D = 0

Perugi et al. (2007) [ 25 ]21.8% of hospitalized BD I patientsM ≥ 3 and affective illness of at least 10 years, D = 0
Open in a separate window

D: depressive episode; M: manic episode.

(b)

Author (year)Duration of follow-upPrevalenceDefinition
Makanjoula (1985) [ 26 ]Five years53% of manic patientsM ≥ 2, D = 0

Solomon et al. (2003) [ 30 ]20 years27 subjects had the diagnosis of unipolar mania at the time of entry. Seven of these did not suffer any depressive episodes during the 15- to 20-year follow-up.Onset with M/HypoM, D = 0 for entire follow-up period

Dakhlaoui et al. (2008) [ 11 ]Five years65.3% of all bipolar I patientsM ≥ 2 and at least 5 years of follow-up, D = 0
Open in a separate window

D: depressive episode; M: manic episode; HypoM: hypomania.

Srinivasan et al. (1982) defined unipolar mania as “3 or more episodes of mania without any depressive” and found its prevalence to be 40% in bipolar inpatients [ 19 ]. Since then, that is, 1990s and further, to label unipolar mania, the number of episodes was increased from 3 to 4 [ 20 – 23 ] or more and without any history of depression. The prevalence in these studies ranged from 16.3% [ 23 ] to 47.2% [ 22 ] among all bipolar patients. But the study design was still retrospective chart review ( Table 1(a) ). Also, there was no consensus on time duration. Aghanwa in 2001 defined unipolar mania as “3 episodes of mania or hypomania and at least 4 years of affective illness” [ 22 ] and Yazici et al. (2002) defined unipolar mania as “4 or more episodes of mania and at least 4 years of follow-up without any depressive episode” [ 23 ].

There had been three prospective studies which have reported the prevalence of UM ( Table 1(b) ).

Recently, a study by Andrade-Nascimento et al. in 2011 evaluated the differences between patients with manic episodes over the course of a 15-year illness duration compared to participants with histories of manic and depressive episodes and found that (5.6%) participants presented with unipolar mania (UM) [ 24 ]. Similarly, Perugi et al., in 2007, found that 21.8% of their patients in a 10-year illness duration were unipolar manic [ 25 ].

4. Sociodemographic Correlates

Most of the studies have not reported any significant difference in age of onset of unipolar mania over bipolar mania [ 13 , 15 , 19 , 20 , 22 , 26 ]. A study on elderly unipolar and bipolar manic patients, however, found that elderly UM patients had an earlier onset [ 27 ]. Another recent study [ 11 ] reported earlier age of onset in unipolar mania (23 years) when compared to bipolar mania (28 years) which was almost similar to the findings of Yazici et al. (2002) [ 23 ].

Regarding gender, the results have been mixed with some early studies reporting a slight male preponderance [ 14 , 28 ] and others finding no difference between both sexes [ 11 , 15 , 18 , 20 , 26 , 29 ]. Furthermore, in other studies, UM was found to be more common in females than males [ 22 , 23 , 30 ].

Marital status [ 22 , 23 , 29 ], educational status [ 23 , 26 , 29 ], and occupational status [ 22 , 29 ] do not differ in unipolar and bipolar mania.

The majority of studies on UM have come from “nonwestern” countries, such as Nigeria [ 26 ], India [ 20 , 21 , 29 ], the Fiji Islands [ 22 ], Turkey [ 23 ], Hong Kong [ 31 ], and Tunisia [ 11 , 32 ], suggesting that UM is more common in these countries. But, due to lack of cross-cultural studies, this cannot be regarded as conclusive. However, a recent cross-cultural study reported that UM was three times more common in Tunisia than in France [ 32 ]. Two studies have been reported from USA. In these studies, the majority of the UM patients came from Iowa [ 15 , 30 ] which was described as being a more rural setting than the other regions studied [ 30 ]. This, according to the authors, was the reason for the different prevalence of UM among various sites. The only study comparing the prevalence of UM among different ethnic groups, carried out in Fiji, found no significant differences in this regard [ 22 ]. Similarly, the ratios of white/black [ 14 ] or Caucasian/other patients [ 15 ] were not different in UM and bipolar mania groups. This probably refutes the possibility of difference in ethnicities being the reason for difference in prevalence of UM in different cultures. It would, however, be premature to propose an explanation based on the results of single study.

5. Clinical Features

Studies on clinical features have revealed some significant differences between UM and bipolar manias ( Table 2 ).

Table 2

Differences in clinical variables between UM and bipolar mania.

Clinical variablesUMBipolar mania
Grandiosity [ 14 , 15 ]MoreLess
Psychotic episodes [ 15 ]MoreLess
Psychotic symptoms [ 23 ]MoreLess
Psychotic first episode [ 23 , 24 ]MoreLess
Congruent psychotic symptoms [ 15 , 25 ]MoreLess
Rapid cycling [ 18 , 23 ]LessMore
Suicidality [ 18 , 23 ]LessMore
Comorbid anxiety disorders [ 24 ]LessMore
Seasonality and seasonal problems [ 29 ]LessMore
Social, familial, and work disability [ 24 , 25 ]LessMore
Marijuana and amphetamine [ 15 ]MoreLess
Hyperthymic temperament [ 23 , 25 ]MoreLess
Open in a separate window

Studies have also reported no differences in phenomenology and other clinical features between UM and bipolar disorders [ 19 ], number of episodes [ 22 , 23 , 29 ], duration of episodes [ 23 ], risk of psychiatric illness in first-degree relatives [ 11 , 15 , 18 , 19 , 22 , 23 , 27 ], and chronotype [ 29 ]. However, an Indian study by Avasthi et al. in 1996 noted that, out of 50 recurrent maniacs, 11 fulfilled the criteria for seasonal affective disorder and had onset in autumn [ 21 ], whereas another study by Mittal et al. (2013) reported spring and summer seasons to be periods of increased vulnerability for manic relapse [ 29 ]. Dakhlaoui et al. in 2008 reported the first episode season to be summer-autumn in UM [ 11 ].

With regard to family history, only Abrams et al. (1979) reported an increased risk of unipolar depression in the first-degree relatives of people diagnosed with UM [ 14 ], whereas Abrams and Taylor (1974) observed that unipolar maniacs had fewer relatives with affective illness, drug abuse, and characterological pathology compared to bipolar patients [ 13 ].

Other factors that may have a role in clinical presentation such as psychosocial variables, exposure to viruses, diet, and prenatal environment also should be taken into consideration in future studies [ 15 ].

6. Diagnostic Stability

Among the studies, the duration of follow-up varies between 6 and 28 years. Nurnberger et al. (1979) reported that over a 4-month follow-up, 29% of the cases were reclassified as true bipolar disorder [ 18 ]. Perris (1982) observed that change in polarity from mania to depression mainly occurred by the third episode and rarely after the eighth episode [ 10 ]. Shulman and Tohen (1994) carried out a prospective chart review of elderly (>65 years) inpatient cohort. In their 27.7 years of follow-up, they did not find any change in polarity in any patient [ 27 ]. Table 3 (a) summarizes the studies based on retrospective chart reviews which assessed the course of UM.

Table 3

(a) Retrospective chart review-based studies assessing the course of UM. (b) Diagnostic stability of UM in prospective studies.

(a)

Author (year)Duration of illness (in years)Comment
Abrams and Taylor (1974) [ 13 ]10.86

Abrams et al. (1979) [ 14 ]11.7

Nurnberger et al. (1979) [ 18 ]29% of patients converted to BD over follow-up of 4 months.

Perris (1982) [ 10 ]Polarity changes from mania to depression after 3rd episode and rare after 8th episode.

Srinivasan et al. (1982) [ 19 ]5

Khanna et al. (1992) [ 20 ]9.5

Avasthi et al. (1996) [ 21 ]7

Aghanwa (2001) [ 22 ]16.6

Yazici et al. (2002) [ 23 ]12
Open in a separate window

(b)

AuthorDuration of follow-upFindings
Makanjoula (1985) [ 26 ]Five yearsOnly 13 out of 104 patients were found to suffer from bipolar disorder.

Solomon et al. (2003) [ 30 ]20 yearsSeven out of 27 (26%) patients continued to have diagnosis of unipolar mania.

Yazici et al. (2008) [ 41 ]Seven years30 out of initial 272 patients continued to be unipolar maniacs.
Open in a separate window

To date, there are three prospective studies which assessed the diagnostic stability of UM ( Table 3(b) ).

7. Laboratory Investigations

7.1. Neuroimaging

Neuroimaging revealed that UM patients had smaller third-ventricular width [ 33 ].

After brain injury, they had higher minimental scores and smaller subcortical, but larger cortical, lesions (primarily in right orbitofrontal and right basotemporal regions) than classical bipolar patients [ 34 ]. However, Cakir et al. (2008) found no differences in terms of neuropsychological tests between euthymic UM and BD patients [ 35 ].

7.2. Blood Chemistry

UM patients had less thyroid autoimmunity during chronic lithium treatment [ 36 ]. Pfohl et al. (1982) found significantly more abnormal blood count or chemistry in bipolar mania [ 15 ].

8. Treatment Issues

One of the most important findings in support of the view that UM is an entity distinct from BD is the difference in treatment response. Although no such difference has been reported with respect to the acute treatment of manic episode, different response characteristics to prophylactic treatment have been reported. The predominance of depression in BD patients has been associated with a better response to lithium maintenance therapy. Two studies compared the UM and BD patients in response to lithium prophylaxis ( Table 4 ).

Table 4

Studies on UM assessing response to lithium prophylaxis.

AuthorFindingsConclusion (response to lithium prophylaxis)
Nurnberger et al. (1979) [ 18 ]Response to lithium prophylaxis similar in patients with UM and BD hospitalized for depression; however, lithium is less effective in BD patients never hospitalized for depression.UM < classical bipolar disorder

Yazici et al. (2002) [ 23 ]Response to lithium prophylaxis similar in patients with UM and BD while using good, moderate, and poor response modes; however, when using responders and nonresponders as response mode, the UM group had significantly fewer responders than the BD.UM < classical BD
Open in a separate window

Husain et al. (1993) reported good response to maintenance ECT in case of an elderly female with recurrent unipolar mania (bipolar disorder, manic as per DSM-III) who was resistant to antipsychotics and mood stabilizers, intolerant to lithium, and treated with 81 ECTs over period of 2 years [ 37 ]. On the other hand, Angst et al. (2004) showed that BD-I is a heterogeneous entity. The “manic” group, namely, UM and BD-I patients with a marked preponderance of manic episodes during the course of illness, appeared to differ from the “classical bipolar” group in terms of some characteristics like lower risk of recurrence, chronicity, and suicide, better academic achievement, and longer duration of euthymia with or without maintenance treatment [ 38 ].

Recently, Yazici and Cakir (2012) [ 39 ] found that the response rate to lithium prophylaxis was significantly less in the UM group than that in the BD group, whereas the response rate to valproate prophylaxis was similar in both groups. These data suggest that valproate may be a better choice for prophylactic treatment in UM patients. Secondly, when the difference in the response to lithium prophylaxis was investigated, comparison of all the bipolar patients (UM and BD groups together) with a manic episode rate of <50% and >50% and <80% and >80% showed that the response rates were lower in the patients with manic preponderance and that the difference increased as the degree of preponderance increased; however, there was no difference when the UM group was excluded from the comparisons. These findings indicate that being less responsive to lithium prophylaxis was associated more closely with UM than with manic preponderance in bipolarity.

9. Summary

The above review of literature clearly indicates that only a handful of studies pertaining to UM are available at present. The available literature shows that there has been no consensus regarding the definitions and diagnostic criteria of UM which has resulted in its prevalence ranging widely from 1.1% to 65.3%. The differences in study design (retrospective versus prospective) could be another factor which might have contributed to this. No differences have been found between UM and bipolar manias in most of the studies on sociodemographic variables like gender, age of onset of illness, marital status, educational status, and occupational status. UM appears to be more common in “nonwestern” countries, but there is substantial lack of cross-cultural studies to reach any firm conclusion. In clinical and/or psychopathological presentation, UM has more premorbid hyperthymic temperament, grandiosity, and psychotic symptoms but less rapid cycling, suicidality, comorbid anxiety disorder, and seasonality than bipolar mania. However, it is a clinically stable diagnosis over a period of time. It has also been reported that UM produces less social and work disability than BD. Regarding neuroimaging findings, UM shows significantly less third-ventricular size than bipolar mania but this awaits replication. As far as treatment is concerned, UM has poor response to lithium prophylaxis and valproate could be a better choice in these patients.

10. Conclusion

The evidence has thus accumulated in favor of UM over the time which indicates that this entity merits further study. There are certain issues which need to be explored and addressed in future. Firstly, there is a need to adopt stricter diagnostic criteria for UM. This would allow for a better interpretation of the data. Secondly, cross-cultural studies are needed to determine and compare the prevalence of UM in different cultures. Thirdly, although some differences in the clinical features of UM and bipolar manias have been found, these are not consistent across studies so as to act as indicators of a particular type of illness. Fourthly, differences in seasonality, neuroimaging, and treatment response point towards neurobiological differences between UM and bipolar manias which requires further inquiry and exploration.

Therefore, the available literature on UM at this point of time does not warrant it to be classified as a distinct disorder. Rather, adding UM as a course specifier to the diagnosis of BD would be a reasonable step to draw the attention of the researchers and guide them for future research in this area.

Conflict of Interests

The author declares that there is no conflict of interests regarding the publication of this paper.

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Psychiatry J. 2014; 2014: 261943.
Published online 2014 Apr 30. doi:  [ 10.1155/2014/261943 ]
PMCID: PMC4020165
PMID: 24877052

Unipolar Mania: Recent Updates and Review of the Literature

Shubham Mehta *

Shubham Mehta

Department of Psychiatry, SMS Medical College, Jaipur Rajasthan 302004, India

Find articles by Shubham Mehta
Author information Article notes Copyright and License information Disclaimer
Department of Psychiatry, SMS Medical College, Jaipur Rajasthan 302004, India
*Shubham Mehta: [email protected]
Academic Editor: Claude Robert Cloninger
Received 2014 Jan 1; Revised 2014 Apr 11; Accepted 2014 Apr 16.
Copyright © 2014 Shubham Mehta.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction. Unipolar mania (UM) has received less than the expected attention, when compared to its contemporary mood disorders, unipolar depression (UD) and bipolar disorder (BD). Method. The literature search included PUBMED and PSYCINFO databases. Cross-searches of key references were made to identify other articles of importance. Results. There seems to be a bipolar subgroup with a stable, unipolar recurrent manic course. Although UM does not have significant differences from bipolar mania in terms of sociodemographic variables, there are certain significant differences in clinical features. UM is reported to have more grandiosity, psychotic symptoms, and premorbid hyperthymic temperament, but less rapid cycling, suicidality, seasonality, and comorbid anxiety disorders. It seems to have a better course of illness with better social and professional adjustment. However, its response to lithium prophylaxis is found to be poor as compared to classical BD and valproate could be a better choice in this case. Conclusion. The available literature suggests that UM has certain differences from classical BD. The evidence, however, is insufficient to categorize it as separate diagnostic entity. However, considering UM as a course specifier of BD would be a reasonable step.

1. Introduction: Unipolar Mania—Then and Now

“Periodic mania” was the term which was first used by Kraepelin (1899) to refer to some of his cases having recurrent manic episodes without depression [ 1 ]. Wernicke (1900) proposed that single or recurrent episodes of mania or depression should be viewed as distinct disorders [ 2 ], separate from the ones which follow the continuous circular course of depression, mania, and free interval or “folie circulaire” as proposed by Falret [ 3 ]. “Phasic psychoses” were then classified by Kleist (1911, 1953) [ 4 , 5 ] and Leonhard (1957) [ 6 ] who labeled pure mania and pure melancholia as “pure phasic psychoses” and manic-depressive psychosis as a “polymorphous phasic psychosis.” Genetic basis for distinction between unipolar mania and manic-depressive psychosis was first suggested by Neele (1949) [ 7 ].

The evolution of unipolar mania (UM) has continued since then, despite not receiving the distinct nosological status in the two most commonly used and accepted classificatory systems of DSM and ICD.

It did not find any place even in the recently introduced DSM-5 [ 8 ]. In the chapter of bipolar and related disorders, DSM-5 has clearly stated that the lifetime experience of major depressive episode is not a requirement for diagnosing bipolar I disorder. This implies that the isolated and recurrent episodes of mania also would fall into the category of bipolar I disorder.

ICD-10, however, has included “recurrent mania NOS” along with bipolar II disorder into the category of “other bipolar affective disorders” [ 9 ].

Thus, UM has received less expected attention than its contemporary mood disorders, unipolar depression (UD) and bipolar disorder (BD). Anyhow, it still manages to sparkle the nosological debate amongst researchers every now and then because there are a sufficient number of patients, reported from several countries and cultures, who demonstrate a recurrent unipolar manic course.

The paper reviews the available literature on unipolar mania. This would be of help to address the question that “whether unipolar mania stands apart as distinct nosological entity or not.” This also would serve to identify the gaps in the literature regarding UM which can guide the future research in this area.

2. Search Methodology

This update is based on the literature search carried out by the author. The literature search included PUBMED and PSYCINFO databases using the following keywords (in different combinations): “unipolar mania, recurrent mania, recurrent unipolar mania, periodic mania, and pure mania.” Cross-searches of key references were made to identify other articles of importance. No publication year limits were applied. The titles and abstracts were examined manually, and full-text articles of potentially relevant studies were obtained.

The available literature has been organized under the headings of prevalence, sociodemographic correlates, clinical features, laboratory investigations, and treatment issues and is discussed in comparison to bipolar mania at most places. Finally, the important findings are summarized and conclusions are made.

3. Prevalence

The prevalence of UM has ranged widely from as low as 1.1% [ 10 ] to as high as 65.3% [ 11 ] mainly because different defining criteria have been used by different researchers.

Perris in 1966 defined unipolar mania as “one or more manic episodes with no depressive episode” and found the prevalence of UM to be 4.5% among all bipolar patients [ 12 ]. This definition was continued to be used in most of the studies [ 10 , 13 – 17 ] in 1970s and early 1980s which used retrospective chart reviews for their analysis. The prevalence of unipolar mania with this definition thus ranged from 1.1% of all bipolar patients [ 10 ] to 35.2% of bipolar inpatients [ 15 ]. Nurnberger et al. (1979), however, defined UM as minimum 1 hospitalization for manic episode and no hospitalization or somatic treatment for depression and found 15.7% of bipolar I disorder patients to be unipolar maniacs [ 18 ]. The retrospective studies which analyzed the prevalence of UM are shown in Table 1(a) .

Table 1

(a) Retrospective studies related to prevalence of UM. (b) Prospective studies related to prevalence of UM.

(a)

Author (year)PrevalenceDefinition
Perris (1966) [ 12 ]4.5% among all BD patientsM ≥ 1, D = 0

Abrams and Taylor (1974) [ 13 ]28% of BD I patientsM-number not defined, D = 0

Nurnberger et al. (1979) [ 18 ]15.7% of BD I patientsM ≥ 1 hospitalization, D = no hospitalization or somatic treatment

Abrams et al. (1979) [ 14 ]18% of BD patientsM ≥ 2, D = 0

Perris (1982) [ 10 ]1.1% of BD patientsM ≥ 1, D = 0

Pfohl et al. (1982) [ 15 ]35.2% of hospitalized BD patientsM ≥ 1, D = 0

Rao et al. (1982) [ 16 ]2.7% of lithium clinic patientsOnly M during follow-up, D = 0

Venkoba Rao and Madhavan (1983) [ 17 ]12% of BD patients
(age of onset >60 years)
Only M during follow-up, D = 0

Srinivasan et al. (1982) [ 19 ]40% of hospitalized BD patientsM ≥ 3, D = 0

Margoob and Dutta (1988) [ 40 ]42% of all BD patientsM = not defined, D = not defined

Khanna et al. (1992) [ 20 ]44% of hospitalized BD patientsM ≥ 4, D = 0

Avasthi et al. (1996) [ 21 ]6.45% of all affective disordersM ≥ 3, D = 0

Aghanwa (2001) [ 22 ]47.2% of all BD patientsM ≥ 3 (includes hypomania as well) and affective illness for at least 4 years, D = 0

Yazici et al. (2002) [ 23 ]16.3% of BD I patientsM ≥ 4 and at least 4 years of follow-up, D = 0

Perugi et al. (2007) [ 25 ]21.8% of hospitalized BD I patientsM ≥ 3 and affective illness of at least 10 years, D = 0
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D: depressive episode; M: manic episode.

(b)

Author (year)Duration of follow-upPrevalenceDefinition
Makanjoula (1985) [ 26 ]Five years53% of manic patientsM ≥ 2, D = 0

Solomon et al. (2003) [ 30 ]20 years27 subjects had the diagnosis of unipolar mania at the time of entry. Seven of these did not suffer any depressive episodes during the 15- to 20-year follow-up.Onset with M/HypoM, D = 0 for entire follow-up period

Dakhlaoui et al. (2008) [ 11 ]Five years65.3% of all bipolar I patientsM ≥ 2 and at least 5 years of follow-up, D = 0
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D: depressive episode; M: manic episode; HypoM: hypomania.

Srinivasan et al. (1982) defined unipolar mania as “3 or more episodes of mania without any depressive” and found its prevalence to be 40% in bipolar inpatients [ 19 ]. Since then, that is, 1990s and further, to label unipolar mania, the number of episodes was increased from 3 to 4 [ 20 – 23 ] or more and without any history of depression. The prevalence in these studies ranged from 16.3% [ 23 ] to 47.2% [ 22 ] among all bipolar patients. But the study design was still retrospective chart review ( Table 1(a) ). Also, there was no consensus on time duration. Aghanwa in 2001 defined unipolar mania as “3 episodes of mania or hypomania and at least 4 years of affective illness” [ 22 ] and Yazici et al. (2002) defined unipolar mania as “4 or more episodes of mania and at least 4 years of follow-up without any depressive episode” [ 23 ].

There had been three prospective studies which have reported the prevalence of UM ( Table 1(b) ).

Recently, a study by Andrade-Nascimento et al. in 2011 evaluated the differences between patients with manic episodes over the course of a 15-year illness duration compared to participants with histories of manic and depressive episodes and found that (5.6%) participants presented with unipolar mania (UM) [ 24 ]. Similarly, Perugi et al., in 2007, found that 21.8% of their patients in a 10-year illness duration were unipolar manic [ 25 ].

4. Sociodemographic Correlates

Most of the studies have not reported any significant difference in age of onset of unipolar mania over bipolar mania [ 13 , 15 , 19 , 20 , 22 , 26 ]. A study on elderly unipolar and bipolar manic patients, however, found that elderly UM patients had an earlier onset [ 27 ]. Another recent study [ 11 ] reported earlier age of onset in unipolar mania (23 years) when compared to bipolar mania (28 years) which was almost similar to the findings of Yazici et al. (2002) [ 23 ].

Regarding gender, the results have been mixed with some early studies reporting a slight male preponderance [ 14 , 28 ] and others finding no difference between both sexes [ 11 , 15 , 18 , 20 , 26 , 29 ]. Furthermore, in other studies, UM was found to be more common in females than males [ 22 , 23 , 30 ].

Marital status [ 22 , 23 , 29 ], educational status [ 23 , 26 , 29 ], and occupational status [ 22 , 29 ] do not differ in unipolar and bipolar mania.

The majority of studies on UM have come from “nonwestern” countries, such as Nigeria [ 26 ], India [ 20 , 21 , 29 ], the Fiji Islands [ 22 ], Turkey [ 23 ], Hong Kong [ 31 ], and Tunisia [ 11 , 32 ], suggesting that UM is more common in these countries. But, due to lack of cross-cultural studies, this cannot be regarded as conclusive. However, a recent cross-cultural study reported that UM was three times more common in Tunisia than in France [ 32 ]. Two studies have been reported from USA. In these studies, the majority of the UM patients came from Iowa [ 15 , 30 ] which was described as being a more rural setting than the other regions studied [ 30 ]. This, according to the authors, was the reason for the different prevalence of UM among various sites. The only study comparing the prevalence of UM among different ethnic groups, carried out in Fiji, found no significant differences in this regard [ 22 ]. Similarly, the ratios of white/black [ 14 ] or Caucasian/other patients [ 15 ] were not different in UM and bipolar mania groups. This probably refutes the possibility of difference in ethnicities being the reason for difference in prevalence of UM in different cultures. It would, however, be premature to propose an explanation based on the results of single study.

5. Clinical Features

Studies on clinical features have revealed some significant differences between UM and bipolar manias ( Table 2 ).

Table 2

Differences in clinical variables between UM and bipolar mania.

Clinical variablesUMBipolar mania
Grandiosity [ 14 , 15 ]MoreLess
Psychotic episodes [ 15 ]MoreLess
Psychotic symptoms [ 23 ]MoreLess
Psychotic first episode [ 23 , 24 ]MoreLess
Congruent psychotic symptoms [ 15 , 25 ]MoreLess
Rapid cycling [ 18 , 23 ]LessMore
Suicidality [ 18 , 23 ]LessMore
Comorbid anxiety disorders [ 24 ]LessMore
Seasonality and seasonal problems [ 29 ]LessMore
Social, familial, and work disability [ 24 , 25 ]LessMore
Marijuana and amphetamine [ 15 ]MoreLess
Hyperthymic temperament [ 23 , 25 ]MoreLess
Open in a separate window

Studies have also reported no differences in phenomenology and other clinical features between UM and bipolar disorders [ 19 ], number of episodes [ 22 , 23 , 29 ], duration of episodes [ 23 ], risk of psychiatric illness in first-degree relatives [ 11 , 15 , 18 , 19 , 22 , 23 , 27 ], and chronotype [ 29 ]. However, an Indian study by Avasthi et al. in 1996 noted that, out of 50 recurrent maniacs, 11 fulfilled the criteria for seasonal affective disorder and had onset in autumn [ 21 ], whereas another study by Mittal et al. (2013) reported spring and summer seasons to be periods of increased vulnerability for manic relapse [ 29 ]. Dakhlaoui et al. in 2008 reported the first episode season to be summer-autumn in UM [ 11 ].

With regard to family history, only Abrams et al. (1979) reported an increased risk of unipolar depression in the first-degree relatives of people diagnosed with UM [ 14 ], whereas Abrams and Taylor (1974) observed that unipolar maniacs had fewer relatives with affective illness, drug abuse, and characterological pathology compared to bipolar patients [ 13 ].

Other factors that may have a role in clinical presentation such as psychosocial variables, exposure to viruses, diet, and prenatal environment also should be taken into consideration in future studies [ 15 ].

6. Diagnostic Stability

Among the studies, the duration of follow-up varies between 6 and 28 years. Nurnberger et al. (1979) reported that over a 4-month follow-up, 29% of the cases were reclassified as true bipolar disorder [ 18 ]. Perris (1982) observed that change in polarity from mania to depression mainly occurred by the third episode and rarely after the eighth episode [ 10 ]. Shulman and Tohen (1994) carried out a prospective chart review of elderly (>65 years) inpatient cohort. In their 27.7 years of follow-up, they did not find any change in polarity in any patient [ 27 ]. Table 3 (a) summarizes the studies based on retrospective chart reviews which assessed the course of UM.

Table 3

(a) Retrospective chart review-based studies assessing the course of UM. (b) Diagnostic stability of UM in prospective studies.

(a)

Author (year)Duration of illness (in years)Comment
Abrams and Taylor (1974) [ 13 ]10.86

Abrams et al. (1979) [ 14 ]11.7

Nurnberger et al. (1979) [ 18 ]29% of patients converted to BD over follow-up of 4 months.

Perris (1982) [ 10 ]Polarity changes from mania to depression after 3rd episode and rare after 8th episode.

Srinivasan et al. (1982) [ 19 ]5

Khanna et al. (1992) [ 20 ]9.5

Avasthi et al. (1996) [ 21 ]7

Aghanwa (2001) [ 22 ]16.6

Yazici et al. (2002) [ 23 ]12
Open in a separate window

(b)

AuthorDuration of follow-upFindings
Makanjoula (1985) [ 26 ]Five yearsOnly 13 out of 104 patients were found to suffer from bipolar disorder.

Solomon et al. (2003) [ 30 ]20 yearsSeven out of 27 (26%) patients continued to have diagnosis of unipolar mania.

Yazici et al. (2008) [ 41 ]Seven years30 out of initial 272 patients continued to be unipolar maniacs.
Open in a separate window

To date, there are three prospective studies which assessed the diagnostic stability of UM ( Table 3(b) ).

7. Laboratory Investigations

7.1. Neuroimaging

Neuroimaging revealed that UM patients had smaller third-ventricular width [ 33 ].

After brain injury, they had higher minimental scores and smaller subcortical, but larger cortical, lesions (primarily in right orbitofrontal and right basotemporal regions) than classical bipolar patients [ 34 ]. However, Cakir et al. (2008) found no differences in terms of neuropsychological tests between euthymic UM and BD patients [ 35 ].

7.2. Blood Chemistry

UM patients had less thyroid autoimmunity during chronic lithium treatment [ 36 ]. Pfohl et al. (1982) found significantly more abnormal blood count or chemistry in bipolar mania [ 15 ].

8. Treatment Issues

One of the most important findings in support of the view that UM is an entity distinct from BD is the difference in treatment response. Although no such difference has been reported with respect to the acute treatment of manic episode, different response characteristics to prophylactic treatment have been reported. The predominance of depression in BD patients has been associated with a better response to lithium maintenance therapy. Two studies compared the UM and BD patients in response to lithium prophylaxis ( Table 4 ).

Table 4

Studies on UM assessing response to lithium prophylaxis.

AuthorFindingsConclusion (response to lithium prophylaxis)
Nurnberger et al. (1979) [ 18 ]Response to lithium prophylaxis similar in patients with UM and BD hospitalized for depression; however, lithium is less effective in BD patients never hospitalized for depression.UM < classical bipolar disorder

Yazici et al. (2002) [ 23 ]Response to lithium prophylaxis similar in patients with UM and BD while using good, moderate, and poor response modes; however, when using responders and nonresponders as response mode, the UM group had significantly fewer responders than the BD.UM < classical BD
Open in a separate window

Husain et al. (1993) reported good response to maintenance ECT in case of an elderly female with recurrent unipolar mania (bipolar disorder, manic as per DSM-III) who was resistant to antipsychotics and mood stabilizers, intolerant to lithium, and treated with 81 ECTs over period of 2 years [ 37 ]. On the other hand, Angst et al. (2004) showed that BD-I is a heterogeneous entity. The “manic” group, namely, UM and BD-I patients with a marked preponderance of manic episodes during the course of illness, appeared to differ from the “classical bipolar” group in terms of some characteristics like lower risk of recurrence, chronicity, and suicide, better academic achievement, and longer duration of euthymia with or without maintenance treatment [ 38 ].

Recently, Yazici and Cakir (2012) [ 39 ] found that the response rate to lithium prophylaxis was significantly less in the UM group than that in the BD group, whereas the response rate to valproate prophylaxis was similar in both groups. These data suggest that valproate may be a better choice for prophylactic treatment in UM patients. Secondly, when the difference in the response to lithium prophylaxis was investigated, comparison of all the bipolar patients (UM and BD groups together) with a manic episode rate of <50% and >50% and <80% and >80% showed that the response rates were lower in the patients with manic preponderance and that the difference increased as the degree of preponderance increased; however, there was no difference when the UM group was excluded from the comparisons. These findings indicate that being less responsive to lithium prophylaxis was associated more closely with UM than with manic preponderance in bipolarity.

9. Summary

The above review of literature clearly indicates that only a handful of studies pertaining to UM are available at present. The available literature shows that there has been no consensus regarding the definitions and diagnostic criteria of UM which has resulted in its prevalence ranging widely from 1.1% to 65.3%. The differences in study design (retrospective versus prospective) could be another factor which might have contributed to this. No differences have been found between UM and bipolar manias in most of the studies on sociodemographic variables like gender, age of onset of illness, marital status, educational status, and occupational status. UM appears to be more common in “nonwestern” countries, but there is substantial lack of cross-cultural studies to reach any firm conclusion. In clinical and/or psychopathological presentation, UM has more premorbid hyperthymic temperament, grandiosity, and psychotic symptoms but less rapid cycling, suicidality, comorbid anxiety disorder, and seasonality than bipolar mania. However, it is a clinically stable diagnosis over a period of time. It has also been reported that UM produces less social and work disability than BD. Regarding neuroimaging findings, UM shows significantly less third-ventricular size than bipolar mania but this awaits replication. As far as treatment is concerned, UM has poor response to lithium prophylaxis and valproate could be a better choice in these patients.

10. Conclusion

The evidence has thus accumulated in favor of UM over the time which indicates that this entity merits further study. There are certain issues which need to be explored and addressed in future. Firstly, there is a need to adopt stricter diagnostic criteria for UM. This would allow for a better interpretation of the data. Secondly, cross-cultural studies are needed to determine and compare the prevalence of UM in different cultures. Thirdly, although some differences in the clinical features of UM and bipolar manias have been found, these are not consistent across studies so as to act as indicators of a particular type of illness. Fourthly, differences in seasonality, neuroimaging, and treatment response point towards neurobiological differences between UM and bipolar manias which requires further inquiry and exploration.

Therefore, the available literature on UM at this point of time does not warrant it to be classified as a distinct disorder. Rather, adding UM as a course specifier to the diagnosis of BD would be a reasonable step to draw the attention of the researchers and guide them for future research in this area.

Conflict of Interests

The author declares that there is no conflict of interests regarding the publication of this paper.

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  • Clin Psychopharmacol Neurosci
  • v.16(2); 2018 May
  • PMC5953021
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Clin Psychopharmacol Neurosci. 2018 May; 16(2): 209–213.
Published online 2018 May 31. doi:  [ 10.9758/cpn.2018.16.2.209 ]
PMCID: PMC5953021
PMID: 29739135

Unipolar Mania: A Particular Aspect of Bipolar Disorder in Tunisia

Badii Amamou ,corresponding author Wafa Chebbi , Myriam Allegue , Ahmed Mhalla , Ferid Zaafrane , and Lotfi Gaha
Author information Article notes Copyright and License information Disclaimer
Department of Psychiatry, University Hospital of Monastir (EPS Fattouma Bourguiba), Monastir, Tunisia
corresponding authorCorresponding author.
Address for correspondence: Badii Amamoum, MD, Department of Psychiatry, University Hospital of Monastir (EPS Fattouma Bourguiba), Avenue Farhat HACHED 5000, Monastir, Tunisia, Tel: +216-98475488, Fax: +216-73460678, E-mail: [email protected] , ORCID: https://orcid.org/0000-0001-5079-6252
Received 2017 Apr 11; Revised 2017 May 4; Accepted 2017 May 11.
Copyright © 2018, Korean College of Neuropsychopharmacology
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0 ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Unipolar mania is a clinical reality in our daily practice. Many authors suggested that bipolar patients can have only manic episodes without depressions. These findings lead us to explore more this particularity.

Methods

We conduct a retrospective, descriptive and comparative study including 173 patients, followed for bipolar disorder type I, according to the Diagnostic and Statistical Manual of Mental Disorders fifth edition criteria, during the period between January 2008 and December 2015. Two groups were identified. The first one was composed of 98 patients who had presented only manic episodes. The second group contained the rest of the sample. Unipolar mania was defined as the presence of three or more manic states without a depressive episode during the period of the study.

Results

One hundred seventy three patients were included in the study. The average age of the sample was 43 years old. The first episode was manic in 129 patients (74.6%). The dominant polarity was manic in 90.8% of the cases. Seasonal characteristic and psychotic symptoms were observed in respectively 11.0% and 53.2% of the sample. Rapid cycling evolution was observed among 2.3% of patients. The unipolar manic profile accounted for 56.6% of the population. This result is equivalent to an annual incidence of 8%. Comparing the two groups, we did not find a significant difference concerning the sociodemographic and clinical variables except for the number of suicide attempts (p=0.014).

Conclusion

Our study shows that unipolar mania is clinical evidence. More studies should be conducted in order to understand its nosological and psychopathological foundations.

Keywords: Unipolar mania, Bipolar disorder, Recurrent mania

INTRODUCTION

The origins of bipolar disorder (BD) trace back to the 19th century, when it was described in the studies of Grinsinger, Baillarger and Falret. 1) However, it was Kraepelin 2) who had associated manic, depressive and mixed states into one category: manic depressive disorder. This classification has revolutionized psychiatry and the term of BD had appeared in the Diagnostic and Statistical Manual of Mental Disorders in its third edition (DSM III). 1) BD is known to be a recurrent mood disorder characterized by the alternation of expansive and depressive mood states separated by free intervals. However, Leonhard 3) had individualized two forms: bipolar and unipolar forms. The bipolar form is characterized by the recurrence of opposed episodes in the same individual, while the unipolar form consists of the recurrence of an only type of mood disorder either depression or mania. Neele was also interested in the genetic basis of this concept and found a distinction between the inheritability of unipolar mood disorders and manic-depressive disorder. 4 , 5) Although the new classification of 5th edition of DSM (DSM 5) did not individualize unipolar mania, this entity retains its relevance for many authors. 6) The prevalence of unipolar mania is variable from one study to another. It represents between 20 to 27% of BD in some studies 7 , 8) and only 5% to 9% in other ones. 6) These findings lead us to explore this particular aspect. From this perspective, the aim of our study was to determine the incidence of unipolar mania in diagnosed bipolar patients and its characteristics.

METHODS

Nature of the Study

We conducted a retrospective, descriptive and comparative study in psychiatric department of University Hospital Fattouma Bourguiba in Monastir, Tunisia during the period between January 2008 and December 2015.

Study Population

We included 173 hospitalized patients who were followed for a BD type I according to DSM 5 criteria for at least one year. 9) Patients who presented an episode due to a medical affection or an antidepressant treatment as well as those who were lost for sight were excluded from the study. We identified two groups. The first group was composed of patients who only presented manic episodes defining the unipolar mania profile. The second group was composed of the rest of the subjects.

Data Collection

Data were collected from interviews with patients and their medical records using to pre-established questionnaire exploring sociodemographic, clinical and therapeutic charactarestics.

Incidence of Unipolar Mania

According to recent studies, we defined unipolar mania as the presence of three or more manic states without a depressive episode during the period of the study. Then, we calculated the incidence of unipolar mania. Since the criterion of judgment is recurrent in the disease, our study will take in consideration the prevalence of unipolar mania.

Statistical Procedure

All data was analyzed using IBM SPSS for Widows software package (ver. 21.0; IBM Co., Armonk, NY, USA). We used Pearson’s chi-square (χ2) tests to compare the variables between the two groups. The significant level of statistical was set at p≤0.05.

RESULTS

The sample was composed of 173 patients whose average age was 43.3±12.2 years old and predominant gender was male (68.2%). Two percent of patients were illiterate and 49.1% had a secondary level education. We found that 34.1% were unemployed and 50.3% were unmarried. The average age of onset was 24.9±8.2 years old and it was considered as early (before 18 years old) in 41 patients and late (after 40 years old) in 9 patients. The average duration of the disease was 17.9±10.2 years old. The first episode was manic in 129 patients (74.6%). A dominant manic polarity was found in 90.8% (n=157) of cases, against depressive polarity in only 9.2% (n=16) of cases. The seasonal characteristic and psychotic symptoms were observed in respectively 11.0% and 53.2% of subjects. The patients of 2.3% had rapid cycling evolution.

Subsequently, we have compared two groups. The first group was composed of patients with three or more manic episodes in the absence of depression, called unipolar mania. Ninety-eight cases of unipolar mania in 7 years were observed. This unipolar manic profile accounted for 56.6% of the population. This result is equivalent to an annual incidence of 8%. The two groups were matched for age and sex and were comparable for sociodemographic and clinical characteristics. A significant difference was only observed concerning the history and the average number of suicide attempts (p<0.001; p=0.014).

The principles characteristics of the sample and its two groups are reported in Table 1 .

Table 1

Sociodemographic and clinical characteristics of the sample

CharacteristicG1 (n=101)G2 (n=72)Sample (n=173)p value
Age (yr)41.7±12.845.4±10.943.3±12.20.05
Sex
 Male71 (70.3)47 (65.3)118 (68.2)0.51
 Famale30 (29.7)25 (34.7)55 (31.8)
Professional status
 Unemployed34 (33.7)25 (34.7)59 (31.4)1
 Employed67 (66.3)47 (65.3)114 (68.6)
History of suicide attempts
 Yes5 (5.0)16 (22.2)21 (12.1)<0.001
 No96 (95.0)56 (77.8)152 (87.9)
Average number of suicide attempts0.13±0.70.49±1.150.28±0.920.014
Addictive behavior8 (7.9)9 (12.5)17 (9.8)0.44
Age on onset (yr)24.23±8.3726±8.0824.95±8.20.17
Mean duration of the disease (yr)17.1±1019.1±10.3817.94±10.170.2
Average number of hospitalizations5.1±4.15.34±3.835±40.69
Seasonal characteristic12 (11.9)7 (9.7)11 (6.4)0.8
Psychotic characteristics60 (59.4)32 (44.4)92 (53.2)0.06
Rapid cycling1 (1)2 (2.8)4 (2.3)0.57
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Values are presented as mean±standard deviation or number (%).

DISCUSSION

Incidence of Unipolar Mania

Among 173 patients who had participated in this study, 98 had only manic episodes which correspond to 56.6% of the sample. In other words, more than half of the study population had unipolar mania profile which is considered as high. Similar results were found in other studies: Dakhlaoui et al. 10) found that 65.3% of bipolar patients had relapsed only on the manic mode and they did not have any depressive episode, while Aghanwa 11) reported a rate of 47.2%. In the most populous country in Africa, Nigeria, recurrent mania is considered as the rule and not the exception. 12 , 13) In the Indian subcontinent, it was observed that as recurrent mania were very common in BD. 14) Chinese study found a high prevalence of recurrent mania while depressions were rare. 15) In a prospective Tunisian study, 35.6% of 129 bipolar patients had only manic states which is lower than our results but is not negligible either. 16) On the contrary, lower percentages were reported in Shulman, Perugi or Yazici’s studies. 17 , 18) European studies found lower levels of unipolar mania between 12% to 25%. 10) A majority of bipolar patients from Spain, USA or Germany spend more than the half of the time in depressive states than in the manic states. 19)

This diversity of results is probably due to the use of different criteria for the definition of the disorder (number of episodes, duration of follow-up, etc.) and the prospective or retrospective nature of the studies. 10 , 11 , 13 , 14 , 17 , 18 , 20 – 29) Indeed, the position of unipolar mania in psychiatric nosology is still controversed. The DSM in its 4th and 5th editions and the International Classification of Diseases, 10th edition (ICD-10) include unipolar mania within the diagnostic entity of BD. 9 , 30 , 31) Since 1990, the number of manic episodes in the definition of unipolar mania has increased from 2 to 4 or more without a history of depression. 11 , 14 , 28) In addition, there was no consensus on the duration of the disease. Aghanwa 11) defined unipolar mania as “3 episodes of mania or hypomania and at least 4 years of disease progression” while Yazici et al. 18) considered it as “4 or more episodes of mania and at least 4 years of follow-up without any depressive episode.” The different definitions and prevalence of unipolar mania are represented in the Table 2 .

Table 2

Different definitions and prevalence of unipolar mania in literature

ReferencePrevalence (%)Definition

ManiaDepression
Perris and d’Elia, 1966 20) 4.5≥10
Abrams and Taylor, 1974 21) 28.0Not defined0
Nurnberger et al., 1979 22) 15.7≥1 hospitalization0 hospitalization
Abrams et al., 1979 23) 18.020
Perris, 1982 17) 1.110
Pfohl et al., 1982 24) 35.210
Rao et al., 19822.710
Rao and Madhavan, 1983 25) 12.010
Srinivasan et al.,1985 26) 40.030
Makanjoula, 198553.020
Margoob and Dutta, 1988 27) 42.0Not definedNot defined
Khanna et al., 1992 14) 44.040
Avasthi et al., 19966.530
Aghanwa, 2001 11) 47.23 (hypo-mania included), duration of the disease at least 4 yr0
Yazici et al., 2002 18) 16.34, at least 4 yr of follow0
Perugi et al., 2007 29) 21.83, duration of the disease at least 10 yr0
Dakhlaoui et al., 2008 10) 65.32, at least 5 yr of follow0
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The high incidence of unipolar mania found in our study can be explained by the differences in the expression of bipolarity between the West and the rest of the world. 15) A recent intercultural study reported that unipolar mania was three times more frequent in Tunisia than in France. 32) This suggests the existence of factors that may affect the expression of the disease. One of these factors is the photoperiod and seasonality. Sunlight and latitude could be determinant factors in the expression of thymic states. 19) Now, it is recognized that circadian rhythm abnormalities have an important role in the course of the trouble. We noticed that countries in where mania was predominant were those having a greater ambient sunlight. 19) Assumptions suggest that CLOCK3111 T/C C/C allele is associated to a higher rate of recurrence. 33) This hypothesis could explain why manic states are predominant in tropical and Mediterranean places. Another suggestion can be advanced and consists on the fact that nutritional habits in Mediterranean countries that are rich in omega-3 and dopaminergic nutriments could protect patients from developing depressions. 15) Moreover, in our country, depressive episodes of moderate intensity are probably underestimated because of the high tolerance to these symptoms by families. 15) According to that, the low rate of depression, found in our study, could be linked to the cultural and religious determinants of the Tunisian society. The “non-recognition” of depression, the stigmatization of mental illness and the tolerance of the entourage could mask a depressive episode.

Sociodemographic and Clinical Profile of Unipolar Mania

Concerning the sociodemographic and clinic profile, patients with unipolar mania did not present significant differences in various parameters apart from the suicide profile. Both the two groups were comparable at the sociodemographic characteristics (age, sex, professional and unmarried status) but also at the clinical aspect (age on onset, duration of the disease, number of hospitalizations, addictive behavior, seasonal and psychotics characteristics, rapid cycling). The studies conducted by Dakhlaoui et al. 10) or Aghanwa 11) did not find, globally, any differences between the two groups. This reinforces our results. Yet, three parameters were found significantly different in the study of Dakhlaoui et al. 10) The addictive behavior was twice higher in bipolar group, the average age of onset was earlier in unipolar group and the seasonal characteristic of the first-episode was considered as different. While unipolar group had their first episode in summer, the bipolar group started its disease in winter. These three parameters were not different in our groups of study. However, other studies have found significant correlation between unipolar mania and some variables such as the female gender, the earlier age at onset, the number of episodes, the occurrence of psychotic symptoms. 14 , 24 , 34) A less occurrence of rapid cycling phenomenon was yet associated to manic states. 18) The only significant difference found in our study was the number of suicide attempts which was higher in the bipolar group. This can be explained by the occurrence of depressive episodes that are characterized by the emergence of ideas of death related to pessimism and despair.

It is important to point out the limits of our study. First, the retrospective nature of our study can be a recall bias. Collecting data from medical files does not allow meticulous examination of the course of the trouble. The number of participants is still reduced and interests only our psychiatric department. Furthermore, depressions with moderate intensity may have been underreported.

In conclusion, unipolar mania appears to be clinical evidence in our socio-demographic context. And the unipolar manic profile accounted for 56.6% of our population. This result is equivalent to an annual incidence of 8%. Many other studies confirmed this finding, especially in tropical and Mediterranean regions. European and American studies does not find similar results as for them, this entity is still contested. Withal, our study raises questions about the place and functions of the inseparable mania of depression and may lead us to reconsider the nosological and psychopathological foundations of mood disorders. Some hypotheses are advanced to explain this variety in the expression and the course of BD. Yet, further studies are still needed to explore this side of the disease.

Acknowledgments

The authors would like to acknowledge the participants of this study. This is a non funded study.

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