Author: Dr. Alice Lam
Dr Alice Lam graduated from the University of Manchester, UK in 1998 and qualified as a General Practitioner in 2002. Her interests include mental health, women’s health, chronic diseases, telehealth, and health communication.
She is a member of the Australian Society for Psychological Medicine, The Australasian Medical Writers Association, and also sits on the Editorial Committee for Hepatitis Australia.
You can read more of her articles and connect with Dr Alice here.
Did you know that 46 million people worldwide are living with bipolar disorder?
This breaks down to a slightly uneven split of 48% male 52% female, and this pattern is seen in almost all countries1.
But are there other ways in which bipolar disorder differs between males and females, and do they really change how males should be treated?
Before we continue, here’s a quick reminder on the main subtypes of bipolar disorder:
Bipolar I is characterized by at least one episode of mania that affects functioning.
Bipolar II is characterized by at least one episode of hypomania (a briefer and less severe form of mania) plus at least one episode of major depression.
Rapid cycling is characterized by at least four episodes of mania, hypomania, depressive or mixed episodes in any 12-month period.
Which subtypes of bipolar disorder are men more likely to have?
Many papers have been written on this controversial topic, but this article (based on various studies) should help to clarify some of the data.
- Bipolar I is seen more in men than women
- Bipolar II is seen less often in men than women2
Do men present with different symptoms compared to women?
According to the results of multiple studies:
- Men experience their first episode of bipolar disorder before women (by 4-5 years) (3)
- Men are more likely present with mania versus women (2), who are more likely to present with depression4
- Men are less likely to have rapid cycling (2) or seasonal episodes than women4
- Men are less likely to have phobia, panic disorder, post-traumatic stress disorder, eating disorders, and borderline personality disorder than women (2)
- Studies suggest that men are less likely to be diagnosed with hypomania, and mixed episodes (5)
- Men and women have similar rates of psychosis (such as delusions and hallucinations) (2)
- Men are reported to have higher rates of conduct and substance use disorders compared to women (2)
What’s the relevance of conduct disorder and substance abuse in men?
Conduct disorder is a clinical definition, which can be characterized as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.” The person diagnosed with conduct disorder has to have met at least three criteria in the past 12 months, which may include bullying or threatening behaviour, use of a weapon, stealing from someone’s person and so on6.
There can be a misperception in the general public and media that people with bipolar disorder, especially men, are physically aggressive and dangerous. The real story is that although there is an increased risk of aggression in men with bipolar disorder this generally only applies to those who have substance abuse problems, that is, those who have addiction problems with tobacco, alcohol or other drugs7.
As well as affecting behavior towards others, we can also see from research that substance abuse, as well as male gender, and younger age of onset are also associated with not sticking with a treatment plan4.
Worryingly, researchers in 2011 suggested that 8% of men and 5% of women with bipolar disorder died from suicide8.
The next logical question is why is there a difference between the figures for men and women? If we could understand the story behind these figures, then surely we can save lives. Here are some points we could consider as relevant:
- We know substance abuse is more common in men. Substance abuse means a slower recovery from bipolar disorder episodes and increased suicidal ideation.
- Substance abuse means the person is less likely to stick with taking medications9
- Being male is a risk factor by itself10. Research continues to find out why
- A Spanish study showed men to be less adherent to treatment than women, possibly related to higher substance abuse rates in men4
- In a New Zealand study of people with bipolar disorder under specialist care, researchers found that men were more likely than women to have substance use disorder, were more likely to be convicted for crimes when unwell, and were also more likely to receive compulsory treatment orders and inpatient treatment11
- Another study based in Sweden showed that women were as likely as men to take the initiative to stop lithium, but twice as likely to consult a doctor before taking action12 (reasons might include perceived lack of effectiveness or side effects). This is a particularly concerning finding when lithium is just as effective for men as it is for women2, and because lithium is still the gold standard treatment for bipolar disorder and the only medication proven to reduce the risk of suicide13
Let’s work with what we can have some control over.
- Substance abuse is seen more frequently in men than women. It reduces speed of recovery, reduces ability to stick to a medication regime, and increases suicide risk. Not only that, but stimulants (like amphetamines and cocaine) may induce mania and consequent risky, dangerous behaviours; and depressants like alcohol and benzodiazepines can trigger or exacerbate depression14. If substances might be affecting your mental health, get help.
- Thinking about stopping medication is not unusual in anyone taking long-term treatment, but if you feel that you no longer need to take a drug, see your doctor first to discuss things further.
- Learn more about what the warning signs are when you are starting to head towards a relapse. Read about warning signs here.
- Seek help and support from trusted people when you need it. Stigma is a complex and strange beast, whether it comes from society or our culture, or even ourselves. Not having compassion for ourselves can get in the way of seeking help, worsening mental health, and then we could get caught in a vicious cycle. Don’t let stigma be a barrier to living life well15,16
- Follow a healthy lifestyle, including a good routine and sleep pattern; reduce stressors where you can. Do things that make you happy.
- Ritchie, H. and Roser, M. (2018). Mental Health. [online] Our World in Data. Available at: https://ourworldindata.org/mental-health [Accessed 11 Apr. 2021].
- Gogos, A. and et al. (2019). Sex differences in schizophrenia, bipolar disorder, and post‐traumatic stress disorder: Are gonadal hormones the link? British Journal of Pharmacology, [online] 176(21), pp.4119–4135. Available at: https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bph.14584 [Accessed 11 Apr. 2021].
- Kennedy, N. and et al. (2005). Gender Differences in Incidence and Age at Onset of Mania and Bipolar Disorder Over a 35-Year Period in Camberwell, England. American Journal of Psychiatry, [online] 162(2), pp.257–262. Available at: https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.2.257 [Accessed 11 Apr. 2021].
- Vega, P. and et al. (2011). Bipolar Disorder Differences between Genders: Special Considerations for Women. Women’s Health, [online] 7(6), pp.663–676. Available at: https://journals.sagepub.com/doi/10.2217/WHE.11.71#articleCitationDownloadContainer [Accessed 9 Apr. 2021].
- Deflorio, A. and Jones, I. (2010). Is sex important? Gender differences in bipolar disorder. [online] International Review of Psychiatry. Available at: https://www.tandfonline.com/doi/full/10.3109/09540261.2010.514601?scroll=top&needAccess=true [Accessed 11 Apr. 2021].
- INSERM Collective Expertise Centre (2015). Conduct: Disorder in children and adolescents. [online] Nih.gov. Available at: https://www.ncbi.nlm.nih.gov/books/NBK7133/ [Accessed 11 Apr. 2021].
- Fazel, S. and et al. (2010). Bipolar Disorder and Violent Crime. Archives of General Psychiatry, [online] 67(9), pp.931–938. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/210872 [Accessed 11 Apr. 2021].
- P, R., Robert and et al. (2017). Bipolar Disorder. 2nd ed. [online] Google Books. Hogrefe Publishing. Available at: https://play.google.com/books/reader?id=3wFQDwAAQBAJ&pg=GBS.PP1 [Accessed 11 Apr. 2021].
- Messer, T. and et al. (2017). https://www.researchgate.net/publication/315886339_Substance_abuse_in_patients_with_bipolar_disorder_a_systematic_review_and_Meta-analysis. [online] ResearchGate. Available at: https://www.researchgate.net/publication/315886339_Substance_abuse_in_patients_with_bipolar_disorder_a_systematic_review_and_Meta-analysis [Accessed 11 Apr. 2021].
- Miller, J.N. and Black, D.W. (2020). Bipolar Disorder and Suicide: a Review. Current Psychiatry Reports, [online] 22(2). Available at: https://link.springer.com/article/10.1007/s11920-020-1130-0 [Accessed 11 Apr. 2021].
- Cunningham, R. and et al. (2020). Gender and mental health service use in bipolar disorder: national cohort study. BJPsych Open, [online] 6(6), p.E138. Available at: https://www.cambridge.org/core/journals/bjpsych-open/article/gender-and-mental-health-service-use-in-bipolar-disorder-national-cohort-study/06F6A2CABEAF9C45E1FCBBC6D7A017FD [Accessed 11 Apr. 2021].
- Öhlund, L. and et al. (2018). Reasons for lithium discontinuation in men and women with bipolar disorder: a retrospective cohort study. BMC Psychiatry, [online] 18(1), p.37. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29415689 [Accessed 11 Apr. 2021].
- Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.
- Jensen, Tom. “Of Mind and Men: Mental Health, Addiction and Hope – International Bipolar Foundation.” International Bipolar Foundation, 2014, ibpf.org/articles/of-mind-and-men-mental-health-addiction-and-hope/. Accessed 11 Apr. 2021.
- Lam, Alice. “Stigma and Bipolar Disorder.” Dr Alice Lam, GP & Health Writer, 2019, www.dralicelam.com/the-write-action/stigma-and-bipolar-disorder. Accessed 11 Apr. 2021.
- Chatmon, Benita N. “Males and Mental Health Stigma.” American Journal of Men’s Health, vol. 14, no. 4, 2020, p. 155798832094932, www.ncbi.nlm.nih.gov/pmc/articles/PMC7444121/, 10.1177/1557988320949322. Accessed 11 Apr. 2021.