Research reportChildhood maltreatment and the course of bipolar disorders among adults: Epidemiologic evidence of dose-response effects
Introduction
Bipolar disorder (BP) is a prevalent disabling disease with high morbidity rates that causes significant burden to patients, families and society (Begley et al., 2001, Gonzalez-Pinto et al., 2010, McIntyre and Konarski, 2004, Moreno et al., 2012). Recent research suggests that sexual, physical and emotional abuse and neglect frequently co-occur and confer increased risk for multiple psychiatric diagnoses including BP (Keyes et al., 2012, McLaughlin et al., 2010). Because childhood emotional, physical and sexual abuse are highly prevalent among individuals with BP (Brown et al., 2005, Leverich et al., 2002), an important question is whether childhood maltreatment (CM), beyond increasing the risk of BP, also worsens its course and prognosis. Another important question is whether there is a dose-response relationship. That is, are number of subtypes of CM associated with increasingly severe clinical characteristics?
A few clinical studies have examined the potential role of CM in the course and outcome of individuals with BP (Brown et al., 2005, Garno et al., 2005, Leverich et al., 2002, Leverich et al., 2003, Post et al., 2003). For example, in a study of 100 adults with BP, a history of severe CM was found in approximately half of adults with BP, with multiple forms of abuse having occurred in about the third (Garno et al., 2005). In another clinical sample, CM was reported by 48.3% of 330 veterans with BP and found that individuals with physical and sexual abuse were more likely to have current post-traumatic stress disorder (PTSD) and lifetime diagnoses of panic disorder and alcohol use disorders (Brown et al., 2005). As part of the Stanley Foundation Bipolar Treatment Outcome Network with a sample of 631 adults with BP, a study found that those with childhood physical or sexual abuse had a history of earlier onset of BP, increased number of Axis I and II comorbid disorders, including a higher rate of suicide attempts (Leverich et al., 2002, Leverich et al., 2003, Post et al., 2003). Furthermore, data from the National Comorbidity Survey Replication (NCS-R) indicate that a history of CM predict earlier onset and longer episode duration of BP (Green et al., 2010, McLaughlin et al., 2010).
We sought to build on those prior studies by examining whether findings of clinical samples extended to individuals with BP in the community. In prior cross-sectional studies using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we found that sexual (Perez-Fuentes et al., 2013) and physical (Sugaya et al., 2012) abuse during childhood was associated with increased risk of having BP, with sexual abuse having stronger effect than physical abuse (OR=4.10 versus OR=3.58). Given the clinical relevance and potential prognostic implications of CM in adults with BP, we sought to examine the clinical characteristics, treatment, lifetime and incidence of psychiatry comorbidity, and functioning of adults with BP-I and BP-II using the NESARC. We hypothesized that among adults with BP there would be a dose response relationship between the number of types of CM and a broad range of variables including age of onset, duration of disorder, rates of comorbidity and rates of treatment seeking for BP.
Section snippets
Sample
The NESARC (Grant et al., 2003b, Grant et al., 2005a) is a longitudinal nationally representative survey whose target population is the civilian, non-institutionalized population of the 50 United States, age 18 and over. Data collection was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and was conducted in two waves using face-to-face interviews. Wave 1 interviews (n=43,093) were conducted between 2001 and 2002 by professional interviewers who had an average of
Prevalence and Sociodemographic Characteristics
Respondents with a lifetime diagnosis of BP-I (n=1172) and BP-II (n=428) in Wave 1 were included in the present study, and were divided into four groups for the purpose of analyses: individuals without CM (45.71%; n=1086), individuals with only one type of maltreatment (23.73%; n=596), individuals with 2 types of maltreatment (12.85%; n=331), and individuals with 3 or more types of maltreatment (17.71%; n=481). Among individuals with BP, 13.57% had physical neglect (PN), 38.44% emotional abuse
Discussion
Around half of individuals with BP had a history of at least one type of CM. Overall, there was a clear dose-response relationship between number of types of CM and severity of BP across several domains, including clinical characteristics, probability of treatment, lifetime prevalence of psychiatric comorbidity, incidence of anxiety disorders, substance use disorder, and nicotine dependence, and level of psychosocial functioning.
In accord with clinical studies in adults (Brown et al., 2005,
Role of funding source
The National Epidemiologic Survey on Alcohol and Related Conditions was sponsored by the National Institute on Alcohol Abuse and Alcoholism with supplemental support from the National Institute on Drug Abuse. Work on this manuscript was supported by NIH grants DA019606, DA020783, DA023200, DA023973, MH082773, and the New York State Psychiatric Institute (Dr. Blanco).
Conflict of interest
This study is supported by NIH grants DA019606, DA020783, DA023200, DA023973, MH076051 (Dr. Blanco). The National Epidemiologic Survey on Alcohol and Related Conditions was funded by the NIAAA, with supplemental support from the National Institute on Drug Abuse. Dr. Goldstein is a consultant for and has received travel support from BMS, has received research support from Pfizer, and has received speaker׳s honoraria from Purdue Pharma. Dr. Sala and Dr. Wang report no financial or other
Acknowledgment
The National Epidemiologic Survey on Alcohol and Related Conditions was sponsored by the National Institute on Alcohol Abuse and Alcoholism with supplemental support from the National Institute on Drug Abuse (NIDA), NIH, USA. Work on this manuscript was supported by NIH grants DA019606, DA020783, DA023200, DA023973, and MH082773, and the New York State Psychiatric Institute (Dr. Blanco). Dr. Sala is currently employed by the Department of Child and Adolescent Psychiatry, Institute of
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