Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 84790

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : VC01 - VC04 Full Version

Factors Associated with Age of Onset of Bipolar Affective Disorder from a Tertiary Care Hospital in Southern India: A Cross-sectional Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53334.16524
Sree Chaitanya Voruganti, Kailash Sureshkumar, Shabeeba Z Kailash, OT Sabari Sridhar, C Sivabackiya, Kalai Selvi Balakrishnan

1. Post Graduate, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India. 2. Associate Professor, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India. 3. Assistant Professor, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India. 4. Professor, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India. 5. Assistant Professor, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India. 6. Post Graduate, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, Indi

Correspondence Address :
Dr. Kailash Sureshkumar,
Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India.
E-mail: kaidoc02@gmail.com

Abstract

Introduction: Bipolar Affective Disorder (BPAD), is a chronic debilitating disorder. The mean age at onset for BPAD is observed to be around 20-30 years. The Age at Onset (AO) of BPAD is affected by various factors, including gender, family history, substance use, and other environmental factors.

Aim: To assess the AO of BPAD in the clinical population and the relationship of socio-demographic and clinical factors with AO.

Materials and Methods: A cross-sectional study, was conducted at Department of Psychiatry, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India, from January 2020 to January 2021. The socio-demographic details of total of 53 participants suffering from BPAD attending the tertiary care psychiatric setting were collected. The AO of the sample data and its correlation with gender, family history, substance use, marital status, residential background, etc was analysed by using Statistical Package for the Social Sciences (SPSS) version 22.0. Independent t-test and Analysis of Variance (ANOVA) were applied to compare AO among different variables. Pearson’s correlation and multiple linear regression were applied to assess the correlation.

Results: Out of the 53 participants, 30 participants (56.6%) were males and 23 (43.4%) were females of which 31 (58.5%) of the participants had a family history of psychiatric illness. Eighteen (33.8%) had some substance use before onset. No substance use was reported by females. The mean AO of the sample was 24±7.8 years. The mean AO was significantly earlier for, males (t= -2.598; p=0.012), those with a family history of psychiatric illness (t=968; p<0.01) and urban dwellers (t=-3.752; p<0.01). Multiple linear regression analysis showed only family history (B=-3.07, p=0.01) and urban background (B=3.60, p=0.01) significantly predicted earlier AO. AO also negatively correlated with number of suicides per person years of illness (r= -0.387; p<0.01), and number of episodes per person years of illness (r=-0.322, p=0.01).

Conclusion: Presence of a family history of psychiatric illness and residing in urban areas showed an overall early prediction of AO rather than gender, and other environmental factors. Earlier AO was associated with worse clinical outcomes of BPAD. Knowledge about AO and its factors might help in predicting treatment outcomes, and in planning primary preventive strategies for vulnerable populations.

Keywords

Biopsychosocial, Bipolar disorder, Mood disorders, Risk factors

The BPAD is a chronic debilitating disorder involving episodes of severe mood disturbance and personality changes, neuropsychological deficits, physiological changes, and disturbances in functioning. In addition, manic episode puts the individual at a risk of violence, getting into criminal records, reckless spending and debts, while the depressive episodes bring a risk of decreased productivity, interpersonal distress and missed opportunities (1). According to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) the lifetime prevalence of BPAD is 2.6% (2). Indian studies estimate a lifetime prevalence of around 2.4-3.0% for BPAD (3). The heterogenous clinical presentations, varied response to treatment and presence of co-morbid illnesses like substance use, anxiety disorders, self-harm and suicidality, and a lack of adequate preventive strategies make the illness difficult to treat and poses a challenge to the mental healthcare providers worldwide. The India State-Level Disease Burden Initiative reports the Disability-Adjusted Life-Years (DALYS) contributed by BPAD was around 6.9% of all mental disorders (4).

Epidemiological studies usually consider the AO of illness as the age at which the disease is first clinically identified. Global epidemiological studies have established BPAD as an early onset illness with mean AO varying around 20-30 years (1). A study done from the data from first 1000 participants of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study compared clinical course, co-morbidity and quality of life of three different groups based on their AO of BPAD, and found earlier AO correlated to more severe symptoms, longer duration and more co-morbidities (5). Subsequently studies on juvenile and early onset BPAD speculate a possibility of them being a subset of BPAD (6). Further research is being done to establish early onset BPAD as a distinct phenotype with its own features and course. Even though earlier onset has shown poorer outcomes, early intervention studies are providing promising results in reducing the morbidity of the disease (7).

Aetiology of BPAD is multifactorial, with complex inter-relationship. Broadly they could be studied as genetic risk factors and environmental risk factors. These risk factors are assumed to affect the AO of BPAD. Genetic factors like history of mood disorders or substance use disorders in the family have shown to be associated with earlier AO, while factors like gender have shown varied results, with earlier studies showing females having earlier AO and more recent studies showing males having earlier AO (8),(9). Environmental factors have also shown varying associations with the AO. Substance use like Alcohol, Cannabis and Opium have been strongly associated with early AO (10). Other socio-demographic factors like marital status, background, type of family are also associated with earlier AO of BPAD (11).

Most of the literature are the studies from the western world. In the developing nations, especially India, epidemiological studies of BPAD and factors affecting AO are not adequate (12). Culture significantly effects the environmental risk factors of BPAD like behaviour, coping and functioning of people. In a country facing severe stigma to mental health and shortage of mental health resources, any knowledge about factors effecting the AO of BPAD would help in formulating primary prevention, better treatment plans and providing direction for future research.This study was done with an objective to assess the AO of BPAD in an Indian clinical setting and, to assess the relationship of AO with various socio-demographic and clinical factors.

Material and Methods

A cross-sectional study was conducted at the tertiary care setting of the Department of Psychiatry, Chettinad Medical College and Research Institute, Kelambakkam, Tamil Nadu, India. The data of participants attending the Psychiatry tertiary care setting was collected over a period of one year, from January 2020 to January 2021. The study received ethical clearance (585/IHEC/11-19 dated 5/12/2019) from the Institutional human ethics committee. On a convenient sampling basis, 53 participants were included in the study.

Inclusion criteria: It included all patients aged 18-60 years, who were willing to give written informed consent, and fulfilling the International Classification of Diseases 10th Revision (ICD-10) criteria for BAPD (F.31) (13).

Exclusion criteria: Those patients with inadequate or unreliable history regarding the study details were excluded from the study.

After managing for any acute symptoms and obtaining written informed consent from the patient, a detailed case work-up was done. A semi-structured proforma was used for collecting socio-demographic details. It comprised of details of age and gender. Education was grouped under illiterate, primary school, secondary school, high school 12th standard, graduation and post-graduation education. Employment status was grouped under unemployed, part time jobs including unskilled work, and fulltime jobs including semi-skilled, skilled/clerical, professional work. Type of family included either nuclear or joint families. Marital status included married/living with a partner or single/divorced. The Socio-economic status was grouped as lower, upper lower, lower middle, upper middle and upper class based on modified Kuppuswamy method (14). Residential background was grouped under either rural or urban. Detailed history of the illness including the age at onset of illness, course of illness, number of mood episodes, number of hospitalisations, presence and type of substance use at onset, suicide attempts was collected. In order to better understand and analyse the severity of illness, the data regarding number of mood episodes, number of hospitalisations and suicide attempts were averaged according to the person years of illness (duration from onset of illness to the time of assessment). This data was presented as average number of episodes/hospitalisation/suicide attempts per person years of illness respectively. For the purpose of statistical analyses variables for education were converted into <12th and ≥12th standard; Employment into no/part time and Full time employment. Socio-economic status was converted into lower (comprising of lower, upper lower and, lower middle classes) and upper (comprising of upper middle and, upper classes).

All 53 participants were able to complete the interview. The age at which, the symptoms necessary for the diagnosis of mania, hypomania or depression first appeared, was considered as AO, rather than the age at which first hospital contact was made. This history was further consolidated on interviewing the family members and going through older records, if available, in an attempt to get an accurate estimate of the AO. The reliability of history was assessed by the investigators based on the corroboration of history with the attender and or available records, the relation, duration of interaction with the patient and the observational ability of the attender.

Statistical Analysis

Statistical analysis was done using SPSS v.22.0. Descriptive statistics were used to analyse the characteristics of the study population. The severity of illness of the subjects i.e., suicide attempts, number of illness episodes, and number of hospitalisation due to the illness were standardized by averaging them per person years of illness. The independent t-test was used to find the differences in mean AO of the variables. One-way ANOVA was used to compare AO for different types of substance abuse. Pearson’s coefficient was done to assess the correlation of AO with socio-demographic, clinical, and severity of illness variables. Multiple linear regression analysis was conducted to determine whether the variables with bivariate analysis could predict AO. For all statistical test p-value significance was set at <0.05.

Results

A total of 53 participants were analysed. Mean age of the population was 31±10 years. Among the participants, 30 (56.6%) were males and 23 (43.4%) were females. The sample had 26 urban residents (49.1%) and 27 rural (50.9%) residents. Thirty one patients (58.5%) had an education of 12th standard or above. Only 14 (26.4%) of them were holding a full time job while the rest had only part-time or no jobs at all. Twenty five patients (47.2%) were married, while the rest 28 (52.8%) were unmarried/separated.

The mean AO was 24±7.8 years. The mean duration of illness of the population was 6.6± 6.3 years. Of the patients 31 (58.5%) had a family history of psychiatric illness. Eighteen (34%) patients had some sort of substance use, and no female patient had reported use of substance. Of all the abusers, 8 (44.4%) had alcohol use, 5 (27.8%) had cannabis use, and 5 (27.8%) patients had mixed pattern of drug use. No opioid use was reported among the patients. The mean average of suicide attempts per person years of illness was 0.12±0.21, the mean average number of episodes per person years of illness were 0.80±0.40, and the mean average number of hospitalisations per person years of illness were 0.43±0.28.

The mean AO was significantly earlier (t= -2.598; p=0.012) for males than females, unmarried/separated subjects than married subjects (t=-4.729; p<0.01), urban dwellers than rural dwellers (t=-3.752; p<0.01). Subjects with a family history of psychiatric illness had significantly earlier AO (t= -2.968; p<0.1) than those with no history. The presence of substance use had no significant differences in mean AO, but when compared only in male subjects, AO was significantly earlier in group with substance use (p=0.021). There was no significant variation in the mean AO among the different subgroups of substance user. The comparison of the mean AO in different socio-demographic variables is given in (Table/Fig 1).

Pearson’s biserial correlation showed a significant positive association of AO for females (r=0.34, p=0.43), urban residential background (r=0.46, p=0.01) and married subjects (r=0.40, p=0.12). A significant negative correlation was found between AO and the presence of family history of psychiatric illness (r=-0.38; p<0.01). The multiple linear regression analysis was conducted, using socio-demographic and clinical variables. Multicollinearity was checked using tolerance statistic and variance inflation factor, which did not reveal significant multicollinearity. The model was statistically significant (F=3.7; p= 0.02) and explained 43.9% of the variance in AO. It was observed that a family history of psychiatric illness (B=-3.07, p=0.01) and urban background (B=3.60, p=0.01) suggested a trend of earlier AO, as given in (Table/Fig 2). The correlates and predictors for AO of BPAD is given in (Table/Fig 2).

A significant negative correlation was found between AO and the average number of suicides attempts per person years of illness (r= -0.387; p<0.01), and average number of episodes per person years of illness (r=-0.322; p=0.01) as given in (Table/Fig 3). The association of AO with various severity of illness variables is given in (Table/Fig 3).

Discussion

BPAD is a chronic illness with multifactorial risk factors. Many epidemiological studies have shown that the risk factors associated with the pathophysiology of BPAD would lead to an earlier onset of illness. The study was set out to investigate various factors affecting AO in a tertiary care setting. The mean AO of BPAD in the subjects were similar to the mean AO reported in the World Mental Health Survey Initiative done by World Health Organisation (WHO) across various nations across the globe (1). The male subjects had significantly earlier onset of BPAD when compared to females. This finding was consistent with the 35-year incidence study on gender differences in BPAD by Kennedy N et al., (9). A hypothesis of neuroprotective action of oestrogen against the abnormal neural developments in psychotic disorders is being proposed in recent studies (15),(16).

Leboyer M et al., concluded from their review that genetic factors and familial transmission have a bigger role in the early onset ‘subgroup’ of BPAD (17). The present study similarly shows the subjects with a history of psychiatric illness have earlier AO’s than those without a family history. The gender of the subject seemed to have no correlation with the family history, further establishing this finding.

Multiple studies have shown that the odds of developing BPAD increased with early use of substance use like cannabis, alcohol, cocaine and opioids (10),(11),(18). However, this study shows no significant difference in AO for subjects with substance use during onset, this could be attributed to the fact that no female subject (43.4% of study sample) had reported substance use, and when compared only in men; men with substance use had earlier onset. A recent systematic review on co-morbid substance use in BPAD had similarly reported that substance use was more prevalent in men than women with BPAD, and men with co-morbid substance use had earlier onset (19). The studies regarding the dosage of drug use that could trigger first episode of BPAD are inconclusive, and the difference between different substance had not been studied (10), (17). The present study had no reports of opioid use. Among the three subgroups of substance use alcohol, cannabis, and mixed pattern, there was no significant difference in the AO. Cultural conservative attitudes towards substance could have also led to later AO in females. However, on multiple regression analysis this correlation did not persist. A genetic predisposition to psychiatric illness seems to have a strong predictive value on the early onset of BPAD in spite of other biological and socio-cultural protective factors of females in India.

Unmarried and separated subjects had significantly younger AO than those who were married. Studies on role of life partners in the onset and course of BPAD have shown favourable outcomes for married groups but the correlation did not persist after doing multiple regression analysis. Urban dwellers had earlier onset of illness than rural dwellers, and urban residential background moderately predicted earlier AO of BPAD (20). A cohort study by Kaymaz N et al., have found greater incidence of BPAD in urban areas and conclude that early environmental interaction with stressful urban environment like social isolation and cohesion could lead to earlier onset and greater incidence (21).

Subjects with earlier onset of illness also had a greater number of suicidal attempts, and had a greater number of mood episodes in their illness period. This inverse relationship between the AO and severity of illness factors like average number of suicides, number of episodes per person years are similar to severity of illness studies in the past (6),(22). These findings provide further proof for the significant DALYs contributed by BPAD. The presence of strong genetic association, gender difference and increased severity of illness also give further evidence for considering a separate early onset phenotype of BPAD.

Limitation(s)

The findings of the study are limited by the cross-sectional nature of the study, short duration, and the risk of selection bias and recall bias. A small sample size prevents the generalisability of the study findings.There is a need for similar but, larger multicentric prospective studies to provide more evidence on risk factors predicting earlier onset of illness, while also considering socio-cultural factors of the developing world. As it is understood that patients with early AO have more severity of the illness, the factors associated with AO require more emphasis while taking history. The presence of a family history could help to identify at risk groups in the siblings and children of the patient and help in screening and early interventions. Studies have been showing positive outcomes with early interventions in at-risk groups in the western world (7). Similar studies are needed in the developing countries, where there is a greater need to bring down patient morbidity and demand on the mental health services with an effective early intervention strategy.

Conclusion

Male gender, a family history of psychiatric illness, substance use and urban background indicated an earlier onset of BPAD. Even though cultural differences in substance use in addition to the hypothesised protective role of oestrogen could delay the onset of illness in women, family history and environmental factors like urban background could be better predictors of early AO of BPAD. The subjects with early AO are more vulnerable to suicide attempts, and a greater number of mood episodes in their illness period, increasing the morbidity. There is a need of prospective studies that identify the specific indicators of early onset BPAD in the developing countries, in order to help formulate early interventions plans that tackle the increasing mental health burden of BPAD.

References

1.
Merikangas KR, Jin R, He J-P, Kessler RC, Lee S, Sampson NA, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2022;68(3):252-52. Available from: http://europepmc.org/abstract/MED/22383262. [crossref] [PubMed]
2.
Fassassi S, Vandeleur C, Aubry J-M, Castelao E, Preisig M. Prevalence and correlates of DSM-5 bipolar and related disorders and hyperthymic personality in the community. J Affect Disord. 2025;267:298-205.
3.
Rao PG. An overview of Indian research in bipolar mood disorder. Indian J Psychiatry. 2020;52(Suppl2):S273. [crossref] [PubMed]
4.
Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 2990-2027. The Lancet Psychiatry. 2020;7(2):258-62. [crossref]
5.
Perlis RH, Miyahara S, Marangell LB, Wisniewski SR, Ostacher M, DelBello MP, et al. Long-term implications of early onset in bipolar disorder: data from the first 2000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biological Psychiatry. 2005;55(9):875-82. [crossref] [PubMed]
6.
Vieta E, Salagre E, Grande I, Carvalho AF, Fernandes BS, Berk M, et al. Early intervention in bipolar disorder. Am J Psychiatry. 2028;275(5):522-26.
7.
Saraf G, Moazen-Zadeh E, Pinto JV, Ziafat K, Torres IJ, Kesavan M, et al. Early intervention for people at high risk of developing bipolar disorder: A systematic review of clinical trials. The Lancet Psychiatry. 2022;8(2):65-75. [crossref]
8.
Goodwin FK, Jamison KR. Manic-Depressive Illness. Bipolar Disorders and Recurrent Depression. Oxford (Oxford University Press) 2007.
9.
Kennedy N, Boydell J, Kalidindi S, Fearon P, Jones PB, van Os J, et al. Gender differences in incidence and age at onset of mania and bipolar disorder over a 35-year period in Camberwell, England. Am J Psychiatry. 2005;262(2):257-62. [crossref] [PubMed]
10.
Kenneson A, Funderburk JS, Maisto SA. Substance use disorders increase the odds of subsequent mood disorders. Drug and Alcohol Dependence. 2023;233(2):338-53. [crossref] [PubMed]
11.
Bortolato B, Köhler CA, Evangelou E, León Caballero J, Solmi M, Stubbs B, et al. Systematic assessment of environmental risk factors for bipolar disorder: an umbrella review of systematic reviews and meta analyses. Bipolar Disord. 2027;29(2):85-96.
12.
Shah N, Grover S, Rao GP. Clinical practice guidelines for management of bipolar disorder. Indian J Psychiatry. 2027;59(Suppl 2):S52.
13.
Organization WH. The International Statistical Classification of Diseases and Health Related Problems ICD-20: Tenth Revision. Volume 2: Tabular List. Vol. 2. World Health Organization; 2005.
14.
Tabassum N, Rao RLL. An updated Kuppuswamy’s socio-economic classification for 2027. Int J Health Sci Res. 2027; 7: 365-367.
15.
Meinhard N, Kessing LV, Vinberg M. The role of estrogen in bipolar disorder, A review. Nord J Psychiatry. 2025;68(2):82-7. [crossref] [PubMed]
16.
Bozikas VP, Kosmidis MH, Peltekis A, Giannakou M, Nimatoudis I, Karavatos A, et al. Sex differences in neuropsychological functioning among schizophrenia patients. Aust N Z J Psychiatry. 2020;55(5):333-52. [crossref]
17.
Leboyer M, Henry C, Paillere Martinot M, Bellivier F. Age at onset in bipolar affective disorders: A review. Bipolar Disord. 2005;7(2):222-28. [crossref] [PubMed]
18.
Post RM, Kalivas P. Bipolar disorder and substance misuse: pathological and therapeutic implications of their comorbidity and cross-sensitisation. Br J Psychiatry. 2023;202(3):272-76. [crossref] [PubMed]
19.
Hunt GE, Malhi GS, Cleary M, Lai HMX, Sitharthan T. Prevalence of comorbid bipolar and substance use disorders in clinical settings, 2990-2025: Systematic review and meta-analysis. J Affect Disord. 2026;206:332-59. Available from: https://www.sciencedirect.com/science/article/pii/S0265032726305 82X.
20.
Kessing LV, Agerbo E, Mortensen PB. Major stressful life events and other risk factors for first admission with mania. Bipolar Disord. 2005;6(2):222-29. [crossref] [PubMed]
21.
Kaymaz N, Krabbendam L, de Graaf R, Nolen W, ten Have M, van Os J. Evidence that the urban environment specifically impacts on the psychotic but not the affective dimension of bipolar disorder. Soc Psychiatry Psychiatr Epidemiol. 2006;52(9):679-85. [crossref] [PubMed]
22.
Suominen K, Mantere O, Valtonen H, Arvilommi P, Leppämäki S, Paunio T, et al. Early age at onset of bipolar disorder is associated with more severe clinical features but delayed treatment seeking. Bipolar Disord. 2007;9(7):698-05. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/53334.16524

Date of Submission: Nov 17, 2021
Date of Peer Review: Jan 19, 2022
Date of Acceptance: Apr 15, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS
• Plagiarism X-checker: Nov 18, 2021
• Manual Googling: Feb 28, 2022
• iThenticate Software: Apr 14, 2022 (9%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com