Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117 DOI 10.1007/s00127-013-0797-5

ORIGINAL PAPER

Cross-national prevalence and cultural correlates of bipolar I disorder Kaja R. Johnson • Sheri L. Johnson

Received: 10 May 2013 / Accepted: 17 November 2013 / Published online: 4 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013

Abstract Purpose Bipolar disorder has been consistently related to heightened sensitivity to reward. Greater reward sensitivity predicts the onset of disorder, a more severe course, and conversion from milder to severe forms. No studies consider whether cultural factors related to reward sensitivity influence the course of bipolar disorder. This study examines the relationship of reward-relevant cultural values to global prevalence rates of bipolar I disorder. Methods Lifetime prevalence of bipolar I disorder for 17 countries was drawn from epidemiological studies that used structured diagnostic interviews of large community samples. Bivariate correlations were used to assess the relationship of bipolar disorder prevalence with national scores on four reward-relevant cultural dimensions (Power Distance, Individualism, Long-Term Orientation, and Performance Orientation). Results The prevalence of bipolar I disorder was correlated in the predicted manner with Power Distance and Individualism, and with Long-Term Orientation and Performance Orientation after outliers were removed. Conclusions Findings provide evidence for a cultural model of reward sensitivity in bipolar disorder. Keywords Bipolar disorder  Culture  Prevalence  Cross-national  Reward sensitivity

K. R. Johnson (&)  S. L. Johnson University of California, Berkeley, 2205 Tolman Hall, Berkeley, CA 94720, USA e-mail: [email protected]

Cross-national prevalence and cultural correlates of bipolar disorder Bipolar disorder is defined by episodes of abnormally and persistently elevated, expansive, or irritable mood (i.e., mania and hypomania). The population suffers from high rates of recurrence, suicidality, and hospitalization, and bipolar disorder has been named as the ninth leading cause of disability in the world [1]. Recent estimates from global population surveys reveal rates of bipolar disorder as high as 4–6 % in adults when broad diagnostic criteria are applied [2–5]. Using the same standardized interview, though, the lifetime national prevalence of DSM-IV diagnoses of bipolar disorder varies widely across countries from 0.1 to over 4 % [6]. There is a need to improve our understanding of the factors that contribute differentially to risk for this disorder. Many studies have found support for the reward system model of bipolar disorder [7]. The reward system is believed to regulate behavior that is directed toward goals. Inputs to the reward system are environmental stimuli that serve as cues or elicitations for goal-directed behavior. Outputs of this system are the manifestations of heightened activity of the system, such as high arousal positive affect [8], sociability, increased incentive motivation, goal-setting, excitement, motor activity [9], and confidence [10]. The strong overlap between these outputs and the symptoms of bipolar disorder was the base for hypotheses that heightened activity of the reward system could produce manic symptoms. High reward sensitivity should be reflected in greater reward system output. Pollen sensitivity is an analogue. Histamine reactions (output) vary depending on the allergen exposure (input) and the individual’s sensitivity to the allergen. In the case of bipolar disorder, people endorse

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elevated reward sensitivity on self-report scales and show enhanced psychophysiological responses to reward-relevant stimuli [11]. High reward sensitivity predicts the onset of bipolar spectrum disorders, conversion to more severe forms of the disorder, and a more severe course of mania in bipolar I [11–13]. Clarifying the inputs to the reward system would inform prevention efforts. In this study, we consider the idea that cultural inputs contribute to heightened output activity of the reward system. Several findings suggest that environmental inputs amplify activity of the reward system. For example, life events involving goal attainment (e.g., getting a new job) can trigger increases in manic symptoms in bipolar I disorder [14, 15] and hypomanic symptoms in bipolar spectrum disorders [16]. In the framework of Bronfenbrenner’s widely recognized model of environmental influences on the individual, these triggers can be conceptualized as forces in the proximal environment [17]. Reward-relevant triggers in the distal environments, or societal and cultural levels, have been hypothesized of bipolar disorder [18], but not yet empirically applied. One study showed that levels of cultural collectivism buffered the effect of genetic susceptibility to anxiety and mood disorders, including bipolar disorder [19]. However, this study was limited in its ability to specify cultural correlates of the particular disorders. Given the substantial variance in global prevalence of bipolar disorder and the centrality of the reward system to bipolar disorder, we consider how four reward-relevant cultural dimensions may contribute to its development.

Cultural inputs to the reward system Reward-relevant dimensions may shape how richly a society provides opportunities for reward pursuit, and how much individuals within that society are encouraged to pursue those rewards. These dimensions, then, may shape the inputs to the reward system, and thereby modulate the activity of this system for individuals living in a given cultural context. Four cultural dimensions relevant for striving for rewards and goals have been well-validated: (1) Power Distance, defined as the degree of power inequality in a society; (2) Individualism–Collectivism, or the degree to which independence or interdependence is stressed in a society; (3) Short- versus Long-Term Orientation, which describes the societal emphasis placed on future-oriented goals and delayed gratification; and (4) Performance Orientation, defined by the extent to which a society values and rewards performance improvement [20, 21]. Power Distance may be less obviously associated with reward compared to the other dimensions, but it is highly relevant in the study of bipolar disorder. It is helpful to consider Power Distance as an index of a cultural valuation

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of a specific type of reward, namely power. In low Power Distance countries, power is not concentrated into a few high ranking individuals, but distributed more equally and is, therefore, more accessible to the mass. In his study of Power Distance, Hofstede theorized that individuals with ‘‘partly satisfied’’ power strivings tend to further strive to maintain or increase that power [20]. It follows, then, that in low Power Distance countries where more individuals experience power, a greater number of people will also experience further power strivings. This corresponds to findings across multiples samples that mania risk (defined by lifetime experiences of subsyndromal manic symptoms) correlates with a heightened motivation to attain power [22]. We hypothesize that prevalence of bipolar disorder will be elevated in low Power Distance national cultures. Cultures that might promote greater activity of the reward system are those that value initiative and achievement (high Individualism), excellence and status (high Performance Orientation), and gratification and quick results (Short-Term Orientation). We therefore also hypothesize that the prevalence of bipolar disorder will be higher in nations with these characteristics.

Methods Estimates of national lifetime prevalence of bipolar I disorder were obtained from several published epidemiological studies. The first was the World Mental Health Survey Initiative, which provided rates for nine countries [6]. The second was the Cross-National Collaborative Group epidemiological study, which provided rates for three countries [23]. Other published epidemiological studies were used to provide estimates for the Netherlands [24], Germany [25], Hungary [26], Ethiopia [27], and Nigeria [28]. Where multiple prevalence estimates were available for the same country, we used the most recently available estimates. All studies included large community samples. Lifetime prevalence rates and study details for each country are provided in Table 1. Bipolar diagnoses Bipolar I disorder is defined in each study by the presence of at least one lifetime episode of mania. Mania is a distinct period of abnormally and persistently elevated, expansive, or irritable mood [29]. It must be accompanied by three of the following manic symptoms (or four with irritable mood): inflated self-esteem, decreased need for sleep, hyper-talkativeness, flight of ideas or subjective experience that thoughts are racing, distractibility, increase in goal-directed activity or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences.

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Table 1 Lifetime prevalence rates of bipolar I disorder in community samples of adults and survey sample characteristics Survey

References

Diagnostic interview

Country

Age (years)

Sample size (no.) Part 1

WMHSI

CNCG

EDSP

Merikangas et al. [6]

Weissman et al. [23]

CIDI/DSM-IV

DIS/DSM-III

Part 2

Lifetime prevalence (%)

Response rate (%)

Brazil

C18

5,037

2,942

0.9

81.3

China

C18

7,134

2,476

0.3

80.0

Colombia

18–65

4,426

2,381

0.7

87.7

India

C18

2,992

1,373

0

98.8

Japan

C20

3,417

1,305

0.1

59.2

Lebanon

C18

2,857

1,031

0.4

70.0

Mexico New Zealand

18–65 C16

5,782 12,790

2,362 7,312

0.7 1.0

76.6 73.3

United States

C18

9,282

5,692

1.0

70.9

Taiwan

C18

11,004*



0.3

90.0

South Korea

C18

5,100*



0.4

83.0

Canada

C18

3,258*



0.6

72.0

3,021*

1.4

71.0 85.0

M-CIDI/DSM-IV

Germany

18–24

HEP

Wittchen et al. [25] Sza´do´czky et al. [26]

DIS/DSM-III-R

Hungary

18–64

2,953



1.5

NEMESIS

Ten Have et al. [24]

CIDI/DSM-III-R

Netherlands

18–64

7,076*



1.3

64.0

BRHP

Negash et al. [27]

CIDI/DSM-IV

Ethiopia

15–49

68,378*



0.5

82.2

NSMHW

Gureje et al. [28]

CIDI/DSM-IV

Nigeria

C18

1,682

0

79.9

4,984

WMHSI World mental health survey initiative, CNCG cross-national collaborative group, EDSP early developmental stages of psychopathology, HEP Hungary epidemiology program, NEMESIS The Netherlands mental health survey and incidence study, BRHP Butajira rural health program, NSMHW Nigerian survey of mental health and well-being, CIDI composite international diagnostic interview, DIS diagnostic interview schedule, DSM diagnostic and statistical manual, M-CIDI Munich-composite international diagnostic interview, dashes not applicable * Studies in these countries used a multistage sampling design, but numbers reported in the original papers represent totals

Although the epidemiological studies used in the current study defined mania using various editions of the diagnostic and statistical manual (DSM), these definitions are highly parallel across iterations. There is only one exception: the specific criterion for mania duration (1 week or any duration if hospitalization is required) was included in DSM-III and DSM-IV, but not in DSM-III-R. The DSMIII-R was used in assessing the samples from the Netherlands and Hungary. Diagnostic interviews in each study were widely used, well validated, and designed for use in epidemiological psychiatric research. These included the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI) [30], the MunichComposite International Diagnostic Interview (M-CIDI) [31], and the National Institute of Mental Health Diagnostic Interview Schedule (DIS) [32–34]. The CIDI is the most widely used for international epidemiological studies of psychiatric illness and has been validated against the Structured Clinical Interview for DSM-IV [35, 36]. The M-CIDI is an adapted (and closely parallel) version of the CIDI. It covers a broader range of diagnoses and uses memory aids to improve participant recall. The M-CIDI has been validated in clinical and community samples and shows good test–retest reliability [37–39]. The DIS relies

on the same mania criteria as the CIDI; the two interviews differ only in that the DIS includes impairment criteria in diagnoses, unlike the CIDI. All interviews are semi-structured with detailed probes concerning each psychiatric syndrome, functional impairment, and medical comorbidities. Diagnoses were derived via computer algorithm, and all interviewers were highly trained to establish reliability before data were collected. Cultural dimensions National scores for Power Distance, Individualism, and Long-Term Orientation were drawn from research by Hofstede [20] and for Performance Orientation from the work of House and colleagues [21]. All scores were based on aggregate scores across large samples (about 88,000 respondents to the Hofstede survey and more than 17,000 respondents to the House survey). The Hofstede scores were based on responses of IBM employees and the House scores were based on surveys of employees in various industries. All four scales have attained strong support as statistically independent of each other [40–42]. Hofstede’s cultural dimensions have been validated in numerous cross-cultural studies across more than 50 countries and groups and are considered a gold standard for

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research on cultural values [20, 41]. In demonstrations of their construct validity, these scales have been correlated with economic, geographic, and demographic indicators [20]. The Performance Orientation scale has been validated against the Hofstede scales and other well-established cultural value dimensions [43], as well as outcomes on the cross-national World Values Survey [44] and objective measures of human behavior collected by agencies of the United Nations (as cited in House, 2004). Analytic method Alpha was set to 0.05, and two-tailed tests were used. All analyses were conducted using version 20 of SPSS. To test hypotheses, bivariate correlations of lifetime prevalence of bipolar I disorder and the four cultural value dimensions were assessed. Case diagnostic methods were used to determine the presence of outliers in four linear regressions of the cultural value dimensions on lifetime prevalence of bipolar I disorder (defined by standardized residual cutoff scores [2 or Cook’s distance [4/n). Where outliers were identified, relationships were reanalyzed without outliers to assess whether correlations significantly changed. Although findings regarding the prevalence of bipolar disorder and socioeconomic status have not been consistent [45, 46], additional analyses were conducted to assess whether controlling for national income level changed the relationship between prevalence and cultural value scores. National income classifications (e.g., low, lower middle, upper middle, high) were obtained from the World Bank Group [47]. Ethiopia, India, and Nigeria were classified as low-income countries; China, Colombia, and Taiwan were lower middle countries; Brazil, Hungary, Lebanon, Mexico, and South Korea were upper middle countries; and Canada, Germany, Japan, the Netherlands, New Zealand, and the United States were high-income countries. First, bivariate correlations were assessed to determine if income level was related to (1) bipolar I prevalence, and (2) the four cultural value dimensions. Then, linear regressions were used to test the independent effects of income level and the cultural value dimensions (entered as independent variables) on bipolar I disorder prevalence (entered as the dependent variable).

Results As a test of hypotheses, bivariate correlations were conducted to examine how each of the four cultural value scales related to the prevalence rates of bipolar I disorder. As hypothesized, higher prevalence rates of bipolar I disorder were associated with lower Power Distance (r = -

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0.68, df = 14, p \ 0.01) and higher Individualism (r = 0.67, df = 14, p \ 0.01). Long-Term Orientation appeared unrelated to the prevalence of bipolar I disorder (r = -0.41, df = 10, p = 0.18). Performance Orientation was only marginally significant but related to prevalence in the predicted direction (r = 0.50, df = 13, p = 0.06). Figure 1 shows these correlations graphically. Outlier analyses for the regression of Power Distance on bipolar I prevalence showed that New Zealand had a large influence (Cook’s D [ 4/n) and that Japan had standardized residuals [2. In the regression of Individualism on prevalence, Hungary and India had large standardized residuals. Nigeria had a large influence and large standardized residuals in the regression of Long-Term Orientation. The Netherlands had large standardized residuals in the regression of Performance Orientation. When bivariate correlations were recomputed without these identified outliers, all four cultural dimensions related significantly in the expected direction to bipolar I disorder prevalence (Power Distance r = -0.78, df = 12, p \ 0.01; Individualism r = 0.77, df = 12, p \ 0.01; Long-Term Orientation r = -0.66, df = 9, p \ 0.03; Performance Orientation r = 0.61, df = 12, p \ 0.03). National income level was correlated with bipolar I prevalence (r = 0.59, df = 15, p \ 0.02) and two cultural dimensions: Power Distance (r = -0.69, df = 14, p \ 0.01) and Individualism (r = 0.71, df = 14, p \ 0.01). Two parallel linear regression models were conducted to examine the effects of Power Distance and Individualism on bipolar I prevalence after accounting for national income level. Neither Power Distance (b = -0.01, t = -1.79, p = 0.10), nor Individualism (b = 0.01, t = 1.62, p = 0.13) were significantly related to bipolar I prevalence after controlling for national income.

Discussion The goal of the current study was to examine how rewardrelevant cultural values relate to national prevalence rates of bipolar I disorder. We hypothesized that ‘‘maniatrophic’’ cultures (P. Blanc, personal communication, September 30, 2013), or cultures that shape a reward-rich environment by placing a high value on the individual pursuit of reward and providing opportunities to do so, would be related to greater prevalence rates. Four well-established cultural dimensions relevant to reward were examined. Prevalence rates were drawn from studies using large community samples and well-validated, reliable diagnostic interviews. The sampled countries represent diverse geographic and economic areas across six continents. As hypothesized, lower Power Distance and higher Individualism were correlated with higher prevalence rates of bipolar I disorder.

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Fig. 1 Correlations of cultural dimensions with cross-national lifetime prevalence of bipolar I disorder across 17 countries. Power Distance and Individualism scores were available for 16 countries. Long-Term Orientation was available for 12 countries. Performance Orientation scores were available for 15 countries. A total of 16

countries was represented across all dimensions. Performance Orientation scale range was 1–7. Long-Term Orientation scale range was 1–100; however, China was added to the data after country scores were fixed [20]

Outliers were important to consider. Lower Long-Term Orientation and higher Performance Orientation were only significantly related to higher prevalence after respectively removing Nigeria and the Netherlands from regression models. Nigeria’s Long-Term Orientation score was relatively low compared to other countries, as is the case among African countries, which score at or below 25 on this scale. There is some evidence suggesting that ShortTerm Orientation in African countries may be qualitatively different from the same in other countries [20]. Given the relatively high prevalence of bipolar I disorder in the Netherlands, Performance Orientation is expected to be

higher, but it is possible that the prevalence estimate is somewhat inflated. Whereas diagnostic criteria for mania were parallel across most samples, prevalence estimates for the Netherlands and Hungary were based on DSM-III-R criteria, which used a broader criterion for mania duration. Perhaps relatedly, their prevalence rates were much higher than other countries (1.3 and 1.5 %, respectively). Analyses of national income revealed no associations with Long-Term Orientation and Performance Orientation, but income did seem to account for a portion of the effects of Power Distance and Individualism, suggesting that income levels may be systematically related to prevalence

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of bipolar disorder. Our use of standardized diagnostic interviews provides more concrete evidence to early studies demonstrating an association between higher income and greater bipolar disorder prevalence [48]. Findings also extend theory regarding income as a correlate of reward system activity within bipolar disorder [49], and suggest that this variable be considered in cultural models of bipolar disorder. Limitations of this study should be noted. Analyses were entirely based on responses aggregated into national level estimates. There is a need to more carefully understand how distal influences operating at a national level guide specific attitudes, contexts, and behaviors for individuals. Methodological limitations include the small number of countries with prevalence estimates. Also of note, samples differed in the maximum age of participants, although most surveys covered the ages during which bipolar onset would be expected [50]. One exception may be Nigeria, where age of onset for mental disorder tends to be higher [28]. This may explain the absence of bipolar cases identified in Nigeria. Greater consistency in diagnostic assessment must be integrated in future epidemiological studies to address methodological limitations. Notwithstanding limitations, the large effect sizes observed here demonstrate how even distal cultural influences may shape the development of bipolar disorder and suggest that developing a cross-cultural model of the disorder is an appropriate and important next step for bipolar disorder research. More specifically, future research should consider how distal influences operating at a national level guide specific attitudes, contexts, and behaviors for individuals. Understanding how reward values at a national level shape individual experiences will help refine clinical models of how to protect the reward sensitive person with bipolar disorder living in an overly-activating culture. In summary, the current study provides one of the first applications of a cultural model to extend the reward system model of bipolar disorder and to explain the variation in the global prevalence of bipolar disorder. The findings suggest that cultural models may enhance understanding of this illness. Acknowledgments The authors thank Dr. Batja Mesquita who is at the Center for Social and Cultural Psychology at KU Leuven, Belgium for her guidance in identifying relevant literature for this study. Conflict of interest of interest.

The authors declare that they have no conflict

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Cross-national prevalence and cultural correlates of bipolar I disorder.

Bipolar disorder has been consistently related to heightened sensitivity to reward. Greater reward sensitivity predicts the onset of disorder, a more ...
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