Socio-demographic and clinical characterization of patients with Bipolar Disorder I vs II: a Nationwide Italian Study

  • A. Carlo Altamura
  • Massimiliano Buoli
  • Bruno Cesana
  • Bernardo Dell’Osso
  • Gianluigi Tacchini
  • Umberto Albert
  • Andrea Fagiolini
  • Andrea de Bartolomeis
  • Giuseppe Maina
  • Emilio Sacchetti
Original Paper


Bipolar disorders (BDs) are prevalent, comorbid and disabling conditions, associated with the highest suicide risk among psychiatric illnesses. In the last few years, new efforts to better characterize the socio-demographic and clinical profiles of BD type I vs II have been documented by several reports, with novel and insightful findings in the field. The present multicenter study aimed to provide a comprehensive and reliable representation of the Italian reality, through the analysis of the largest national sample of bipolar patients collected so far. A total of 1500 patients (BD I n = 963 and BD II n = 537) from different psychiatric departments, participating in the Italian Chapter of the “International Society of Bipolar Disorders” (ISBD), were assessed and divided into two groups on the basis of their diagnostic subtype, and different socio-demographic and clinical variables were compared between the two subgroups. Chi-squared tests for categorical variables and t tests for continuous variables were performed for group comparison. Furthermore, a multivariable logistic regression was performed, considering diagnostic bipolar subtype (type I or II) as dependent variable, and socio-demographic/clinical characteristics as independent variables. BD I vs II patients showed an overall less favorable socio-demographic and clinical profile. In addition, the multivariable logistic regression showed that BD II vs BD I was predicted by the absence of lifetime suicide attempts (OR = 1.58, p = 0.01), a later age of diagnosis (OR = 1.03, p < 0.01), less hypomanic episodes in the last year (OR = 2.29, p < 0.0001) and absence of psycho-educational interventions in the last year (OR = 0.51, p < 0.01). BD I and II patients were found to significantly differ in relation to specific clinical variables, which should be considered within updated diagnostic–therapeutic algorithms.


Bipolar disorder (BD) BD type I BD type II Socio-demographic features Clinical variables 


Compliance with ethical standards

Conflict of interest

The authors do not have any conflicts of interest with the present manuscript. Local ethics committees have approved the present research.


  1. 1.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th Edition, (DSM-5). American Psychiatric Press, Washington DCCrossRefGoogle Scholar
  2. 2.
    Wittchen HU, Mhlig S, Pezawas L (2003) Natural course and burden of bipolar disorders. Int J Neuropsychopharmacol 6:145–154CrossRefPubMedGoogle Scholar
  3. 3.
    Ketter TA (2010) Handbook of diagnosis and treatment of bipolar disorder. American Psychiatric Publishing, Inc., Washington, DCGoogle Scholar
  4. 4.
    Ghaemi SN, Dalley S (2014) The bipolar spectrum: conceptions and misconceptions. Aust N Z J Psychiatry 48:314–324CrossRefPubMedGoogle Scholar
  5. 5.
    Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rössler W (2003) Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 73:133–146CrossRefPubMedGoogle Scholar
  6. 6.
    Angst J, Gamma A, Bowden CL, Azorin JM, Perugi G, Vieta E, Young AH (2013) Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients with major depressive episodes in the Bridge Study: validity and comorbidity. Eur Arch Psychiatry Clin Neurosci 263:663–673CrossRefPubMedGoogle Scholar
  7. 7.
    Judd LL, Akiskal HS (2003) The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord 73:123–131CrossRefPubMedGoogle Scholar
  8. 8.
    Dell’Osso B, Holtzman JN, Goffin KC et al (2015) American tertiary clinic-referred bipolar II disorder compared to bipolar I disorder: More severe in multiple ways, but less severe in a few other ways. J Affect Disord 188:257–262CrossRefPubMedGoogle Scholar
  9. 9.
    Endicott J, Nee J, Andreasen N, Clayton P, Keller M, Coryell W (1985) Bipolar II. Combine or keep separate? J Affect Disord 8:17–28CrossRefPubMedGoogle Scholar
  10. 10.
    Judd LL, Akiskal HS, Schettler PJ et al (2003) A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 60:261–269CrossRefPubMedGoogle Scholar
  11. 11.
    Judd LL, Schettler PJ, Akiskal HS et al (2003) Long-term symptomatic status of bipolar I vs. bipolar II disorders. Int J Neuropsychopharmacol 6:127–137CrossRefPubMedGoogle Scholar
  12. 12.
    Goodwin FK, Jamison KR (2007) Manic-depressive illness. Bipolar disorders and recurrent depression, 2nd edn. Oxford University Press, Oxford, UKGoogle Scholar
  13. 13.
    Rihmer Z, Szádóczky E, Füredi J, Kiss K, Papp Z (2001) Anxiety disorders comorbidity in bipolar I, bipolar II and unipolar major depression: results from a population-based study in Hungary. J Affect Disord 67:175–179CrossRefPubMedGoogle Scholar
  14. 14.
    Henry C, Van den Bulke D, Bellivier F, Etain B, Rouillon F, Leboyer M (2003) Anxiety disorders in 318 bipolar patients: prevalence and impact on illness severity and response to mood stabilizer. J Clin Psychiatry 64:331–335CrossRefPubMedGoogle Scholar
  15. 15.
    Baldessarini RJ, Tondo L, Floris G, Hennen J (2000) Effects of rapid cycling on response to lithium maintenance treatment in 360 bipolar I and II disorder patients. J Affect Disord 61:13–22CrossRefPubMedGoogle Scholar
  16. 16.
    Kupka RW, Luckenbaugh DA, Post RM, Leverich GS, Nolen WA (2003) Rapid and non-rapid cycling bipolar disorder: a meta-analysis of clinical studies. J Clin Psychiatry 64:1483–1494CrossRefPubMedGoogle Scholar
  17. 17.
    Benazzi F (2004) Bipolar II disorder family history using the family history screen: findings and clinical implications. Compr Psychiatry 45:77–82CrossRefPubMedGoogle Scholar
  18. 18.
    Dunner DL, Gershon ES, Goodwin FK (1976) Heritable factors in the severity of affective illness. Biol Psychiatry 11:31–42PubMedGoogle Scholar
  19. 19.
    Rihmer Z, Pestality P (1999) Bipolar II disorder and suicidal behavior. Psychiatr Clin North Am 22:667–673CrossRefPubMedGoogle Scholar
  20. 20.
    Baek JH, Park DY, Choi J et al (2011) Differences between bipolar I and bipolar II disorders in clinical features, comorbidity, and family history. J Affect Disord 131:59–67CrossRefPubMedGoogle Scholar
  21. 21.
    Novick DM, Swartz HA, Frank E (2010) Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord 12:1–9CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Valtonen H, Suominen K, Mantere O, Leppämäki S, Arvilommi P, Isometsä ET (2005) Suicidal ideation and attempts in bipolar I and II disorders. J Clin Psychiatry 66:1456–1462CrossRefPubMedGoogle Scholar
  23. 23.
    Merikangas KR, Jin R, He JP et al (2011) Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 68:241–251CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Vieta E, Gastó C, Otero A, Nieto E, Vallejo J (1997) Differential features between bipolar I and bipolar II disorder. Compr Psychiatry 38:98–101CrossRefPubMedGoogle Scholar
  25. 25.
    Bega S, Schaffer A, Goldstein B, Levitt A (2012) Differentiating between bipolar disorder types I and II: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Affect Disord 138:46–53CrossRefPubMedGoogle Scholar
  26. 26.
    Dell’Osso B, Dobrea C, Cremaschi L et al (2016) Italian Bipolar II vs I patients have better individual functioning, in spite of overall similar illness severity. CNS Spectr Online. doi: 10.1017/S1092852915000887 Google Scholar
  27. 27.
    Holtzman JN, Miller S, Hooshmand F et al (2015) Childhood-compared to adolescent-onset bipolar disorder has more statistically significant clinical correlates. J Affect Disord 179:114–120CrossRefPubMedGoogle Scholar
  28. 28.
    Coryell W, Leon AC, Turvey C, Akiskal HS, Mueller T, Endicott J (2001) The significance of psychotic features in manic episodes: a report from the NIMH collaborative study. J Affect Disord 67:79–88CrossRefPubMedGoogle Scholar
  29. 29.
    Goffin KC, Dell’Osso B, Miller S et al (2016) Different characteristics associated with suicide attempts among bipolar I versus bipolar II disorder patients. J Psychiatr Res 76:94–100CrossRefPubMedGoogle Scholar
  30. 30.
    Tondo L, Baldessarini RJ (2016) Suicidal behavior in mood disorders: response to pharmacological treatment. Curr Psychiatry Rep 18:88CrossRefPubMedGoogle Scholar
  31. 31.
    Conus P, Macneil C, McGorry PD (2014) Public health significance of bipolar disorder: implications for early intervention and prevention. Bipolar Disord 16:548–556CrossRefPubMedGoogle Scholar
  32. 32.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th Edition, Text Revision (DSM-IV-TR). American Psychiatric Press, Washington DCCrossRefGoogle Scholar
  33. 33.
    Sheehan DV, Lecrubier Y, Sheehan KH et al (1998) The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59:22–33PubMedGoogle Scholar
  34. 34.
    Vieta E, Pacchiarotti I, Valentí M, Berk L, Scott J, Colom F (2009) A critical update on psychological interventions for bipolar disorders. Curr Psychiatry Rep 11:494–502CrossRefPubMedGoogle Scholar
  35. 35.
    Colom F, Vieta E, Suppes T (2015) Predominant polarity in bipolar disorders: refining or redefining diagnosis? Acta Psychiatr Scand 132:324–326CrossRefPubMedGoogle Scholar
  36. 36.
    Kupka RW, Altshuler LL, Nolen WA et al (2007) Three times more days depressed than manic or hypomanic in both bipolar I and bipolar II disorder. Bipolar Disord 9:531–535CrossRefPubMedGoogle Scholar
  37. 37.
    Benazzi F (2005) The relationship of major depressive disorder to bipolar disorder: continuous or discontinuous? Curr Psychiatry Rep 7:462–470CrossRefPubMedGoogle Scholar
  38. 38.
    Angst J, Angst F, Gerber-Werder R, Gamma A (2005) Suicide in 406 mood-disorder patients with and without long-term medication: a 40 to 44 years’ follow-up. Arch Suicide Res 9:279–300CrossRefPubMedGoogle Scholar
  39. 39.
    Tondo L, Isacsson G, Baldessarini R (2003) Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs 17:491–511CrossRefPubMedGoogle Scholar
  40. 40.
    Zaninotto L, Souery D, Calati R, Camardese G, Janiri L, Montgomery S et al (2015) Dimensions of delusions in major depression: socio-demographic and clinical correlates in an unipolar-bipolar sample. Clin Psychopharmacol Neurosci 13:48–52CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB et al (2009) Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 166:173–181CrossRefPubMedGoogle Scholar
  42. 42.
    Cassidy F (2011) Risk factors of attempted suicide in bipolar disorder. Suicide Life Threat Behav 41:6–11CrossRefPubMedGoogle Scholar
  43. 43.
    Undurraga J, Baldessarini RJ, Valenti M, Pacchiarotti I, Vieta E (2012) Suicidal risk factors in bipolar I and II disorder patients. J Clin Psychiatry 73:778–782CrossRefPubMedGoogle Scholar
  44. 44.
    Altamura AC, Buoli M, Serati M (2011) Duration of illness and duration of untreated illness in relation to drug response in psychiatric disorders. Neuropsychiatry 1:81–90CrossRefGoogle Scholar
  45. 45.
    Tondo L, Pompili M, Forte A, Baldessarini RJ (2016) Suicide attempts in bipolar disorders: comprehensive review of 101 reports. Acta Psychiatr Scand 133:174–186CrossRefPubMedGoogle Scholar
  46. 46.
    Ozyildirim I, Cakir S, Yazici O (2010) Impact of psychotic features on morbidity and course of illness in patients with bipolar disorder. Eur Psychiatry 25:47–51CrossRefPubMedGoogle Scholar
  47. 47.
    Altamura AC, Buoli M, Caldiroli A et al (2015) Misdiagnosis, duration of untreated illness (DUI) and outcome in bipolar patients with psychotic symptoms: a naturalistic study. J Affect Disord 182:70–75CrossRefPubMedGoogle Scholar
  48. 48.
    Ghanbari Jolfaei A, Ghadamgahi P, Ahmadzad-Asl M, Shabani A (2016) Demographic and diagnostic features of 3147 inpatients with mood disorders in Iran. Iran J Psychiatry Behav Sci 10:e2298PubMedPubMedCentralGoogle Scholar
  49. 49.
    Altamura AC, Buoli M, Albano A, Dell’Osso B (2010) Age at onset and latency to treatment (duration of untreated illness) in patients with mood and anxiety disorders: a naturalistic study. Int Clin Psychopharmacol 25:172–179CrossRefPubMedGoogle Scholar
  50. 50.
    Serati M, Buoli M, Altamura AC (2015) Factors that affect duration of untreated illness in pregnant women with bipolar disorder. Am J Obstet Gynecol 213:876CrossRefPubMedGoogle Scholar
  51. 51.
    Perlis RH (2005) Misdiagnosis of bipolar disorder. Am J Manag Care 11:271–274Google Scholar
  52. 52.
    Patel R, Shetty H, Jackson R (2015) Delays before diagnosis and initiation of treatment in patients presenting to mental health services with bipolar disorder. PLoS One 10:e0126530CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Gigante AD, Barenboim IY, Dias RD, Toniolo RA, Mendonça T, Miranda-Scippa  et al (2016) Psychiatric and clinical correlates of rapid cycling bipolar disorder: a cross-sectional study. Rev Bras Psiquiatr 38:270–274CrossRefPubMedGoogle Scholar
  54. 54.
    Rosa AR, Cruz N, Franco C, Haro JM, Bertsch J, Reed C, Aarre TF et al (2010) Why do clinicians maintain antidepressants in some patients with acute mania? Hints from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a large naturalistic study. J Clin Psychiatry 71:1000–1006CrossRefPubMedGoogle Scholar
  55. 55.
    Benazzi F (2005) Agitated depression in bipolar II disorder. World J Biol Psychiatry 6:198–205CrossRefPubMedGoogle Scholar
  56. 56.
    Stafford N, Colom F (2013) Purpose and effectiveness of psychoeducation in patients with bipolar disorder in a bipolar clinic setting. Acta Psychiatr Scand 442:11–18CrossRefGoogle Scholar
  57. 57.
    Altamura AC, Goikolea JM (2008) Differential diagnoses and management strategies in patients with schizophrenia and bipolar disorder. Neuropsychiatr Dis Treat 4:311–317CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    van der Werf-Eldering MJ, van der Meer L, Burger H, Holthausen EA, Nolen WA, Aleman A (2011) Insight in bipolar disorder: associations with cognitive and emotional processing and illness characteristics. Bipolar Disord 13:343–354CrossRefPubMedGoogle Scholar
  59. 59.
    Depp CA, Harmell AL, Savla GN, Mausbach BT, Jeste DV, Palmer BW (2014) A prospective study of the trajectories of clinical insight, affective symptoms, and cognitive ability in bipolar disorder. J Affect Disord 152–154:250–255CrossRefPubMedGoogle Scholar
  60. 60.
    da Silva Rde A, Mograbi DC, Camelo EV et al (2015) Insight in bipolar disorder: a comparison between mania, depression and euthymia using the insight scale for affective disorders. Trends Psychiatry Psychother 37:152–156CrossRefGoogle Scholar
  61. 61.
    Bond K, Anderson IM (2015) Psychoeducation for relapse prevention in bipolar disorder: a systematic review of efficacy in randomized controlled trials. Bipolar Disord 17:349–362CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • A. Carlo Altamura
    • 1
  • Massimiliano Buoli
    • 1
  • Bruno Cesana
    • 2
  • Bernardo Dell’Osso
    • 1
  • Gianluigi Tacchini
    • 1
  • Umberto Albert
    • 3
  • Andrea Fagiolini
    • 4
    • 5
  • Andrea de Bartolomeis
    • 6
  • Giuseppe Maina
    • 3
  • Emilio Sacchetti
    • 7
  1. 1.Department of PsychiatryUniversity of Milan, Fondazione IRCCS Ca’Granda Ospedale Maggiore PoliclinicoMilanItaly
  2. 2.Unit of Biostatistics and BiomathematicsUniversity of BresciaBresciaItaly
  3. 3.Psychiatric Unit, Department of Neuroscience, S. Luigi Gonzaga HospitalUniversity of TurinOrbassanoItaly
  4. 4.Department of Mental HealthUniversity of Siena Medical CenterSienaItaly
  5. 5.Department of Molecular MedicineUniversity of Siena Medical CenterSienaItaly
  6. 6.Section of Psychiatry and Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Reproductive Science and Odontostomatology, School of MedicineUniversity “Federico II”NaplesItaly
  7. 7.Psychiatric Unit, School of MedicineUniversity of BresciaBresciaItaly

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