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ORIGINAL ARTICLE

Subsyndromal states in bipolar disorder

Dushad Ram, Daya Ram1

Department of Psychiatry, JSS Medical College Hospital, Mysore, and 1Central Institute of Psychiatry, Ranchi, Jharkhand,
India

ABSTRACT

Background: Despite adequate treatment, patients with bipolar disorder suffer from subsyndromal symptoms. This
study has been done to see the association of subsyndromal symptoms with age of onset, duration of illness, duration
of episodes, and number of episodes.
Aims: To know the prevalence of subsyndromal symptoms and their relationship with age of onset, total duration of
illness, number of episodes, and duration of episodes in patients with bipolar disorder in remission.
Materials and Methods: The study was cross sectional and hospital based. One hundred patients, aged between 18 and
65 years, diagnosed as bipolar disorder according to Research Diagnostic Criteria of ICD-10, and with good compliance
with the prophylactic medications, score of 5 on Becks Mania Rating Scale (BMRS) and score 8 on Hamilton
Depression Rating Scale (HDRS) were recruited by the purposive sampling method. Descriptive statistics were used to
describe various sample characteristics. Group differences for categorical variables were examined with the chi-square
test, whereas an independent t test was used for continuous variables.
Results: The most common manic symptom was a decrease in sleep (49%), followed by an increase in verbal activity
(39%), hostility (37%), and increase in motor activity (33.33%). The subsyndromal manic group had a lower age of
onset (58.8%), males (82.4%), unemployed (23.5%), educated (80.4%). There was no significant difference between
with and without subsyndromal mania groups with respect to age, age of onset, duration of illness, number of episode,
and average duration of episode.
Conclusion: Subsyndromal manic symptoms are prevalent and have no relationship with current age, age of onset
of illness, duration of illness, number of episode, and average duration of illness in patient with bipolar disorder in
remission.
Key words: Bipolar disorder, subsyndromal symptoms

INTRODUCTION
The specification of diagnostic algorithms and cut off scores
has led to the new controversy as to whether the subthreshold/subsyndromal symptoms are a clinical problem at
all, or separate phenomenon in their own right, or a minor
form of major disorder, or methodological artifact created
by possibly invalid definition of algorithms and threshold in
Address for correspondence: Dr. Dushad Ram,
Department of Psychiatry, JSS Medical College Hospital,
MG Road, Mysore - 570 004, India.
E-mail: akashji1972@gmail.com
DOI: 10.4103/0019-5545.74314

How to cite this article: Ram D, Ram D. Subsyndromal states

in bipolar disorder. Indian J Psychiatry 2010;52:367-70.
Indian Journal of Psychiatry 52(4), Oct-Dec 2010

the present classification systems. Such symptoms are often

seen in patients with bipolar disorder and is contrary to the
traditional view of remission as cardinal feature.[1] Studies
revealed prevalence of subsyndromal symptoms in bipolar
disorder ranging from 13 to 70%.[2-5] However, some studies
have failed to detect such symptoms.[6] There are few studies
done on subsyndromal mania in bipolar disorder in India
and tended to focus more on subsyndromal depression. The
current study was under taken to find out sociodemographic
correlates of subsyndromal manic symptoms in patients
with bipolar disorder.
MATERIALS AND METHODS
The study was cross sectional and hospital based conducted
at Central Institute of Psychiatry, Ranchi. It has got a
wide catchments area that includes Bihar, Uttar Pradesh,
West Bengal, Himachal Pradesh, Orissa, Madhya Pradesh,
367

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Ram and Ram: Sub syndromal mania in bipolar disorder

Chhattisgarh, and neighboring countries like Nepal, Bhutan,

and Bangladesh.

continuous data, mean standard deviation, and t test were

used.

A total of 100 remitted bipolar patient living in the community

after the treatment of the acute phase of illness and currently
only on prophylactic mood stabilizer, with regular follow
up, were recruited for this study by the purposive sampling
method provided they fulfilled the inclusion and exclusion
criteria. Inclusion criteria were both male and female
patients, aged between 18 and 65 years, with a diagnosis of
bipolar diagnosis according to RDC of ICD 10 criteria,[7] and
on prophylactic mood stabilizer with a good compliance.
Exclusion criteria were significant medical illness or comorbidity, presence of any other psychiatric disorders, last
episode mixed, score 5 or more on BMRS,[8] and score 8 or
more on HDRS.[9] Information was collected from the patient
him/herself, key person/relative accompanying the patient,
case record, and treating psychiatrist.

RESULT

Tool for assessment used in this study are as follows.

1. Socio-demographic and clinical proforma: This consist
of patient details including age, sex, occupation,
education, age of onset of illness, present history of
illness, past history of psychiatric and medical illness,
personal history, duration of episode, dose of mood
stabilizer, compliance, physical, and mental status
examinations and diagnosis.
2. Becks mania rating scale.[8] It consists of 11 items. A total
score 0 to 4 indicates no syndrome. A score of 5 or
more indicates a manic syndrome. In order to make
the diagnosis of subsyndromal mania this scale was
modified as follows: score of 0 = no sub syndrome,
score 1-4 = sub syndrome is present.
3. Hamilton depression rating scale.[9] The enlarged Hamilton
depression rating scale consists of the 17 original
Hamilton items and 5 Bech-Refaelsen items given in
the depression scale. A total score of 0-7 indicates that
there is no depression. A score of 8 or more shows that
depression is present. In order to make the diagnosis
of subsyndromal depression, this scale was modified as
follows: score of 0 = no syndrome and score of 1-7=
sub syndrome present.
4. Udvalg for kliniske undersogelser scale for side effect.[10]
This is an observer scale for assessment of side
effects of drugs. The interview was supplemented by
clinical observation and information obtained from
relatives and/or case records. If there was discrepancy
between patients symptoms and clinical signs, clinical
observation was given precedence. Each item was rated
on 4 item scale (0, 1, 2, and 3). 0 indicating not or
doubtfully present and referred as normal.
Statistical analysis
The data were analyzed by using statistical package for
social science-version 10.1 (SPSS-10). For categorical
data, frequency, percentage and chi-square tests, and for
368

A majority of the patients had age of onset before 30 years

(54%), male (76%), married (79%), living in joint family (71%),
belonged rural area (59%), and educated between middle to
intermediate level (74%) [Table 1].
The most common manic symptom was decrease in sleep
(49%). Other symptoms were an increase in verbal activity
(39%), hostility (37%), increase motor activity (33.33%),
elevated mood (27.45%), inflated self-esteem (15.7%), and
flight of idea (5.9%). Common side effects seen were tremor
(25%) difficulty in concentration (7%) [Table 2].
The data analysis showed [Tables 1 and 2] that in the
subsyndromal mania group a large number had lower age of
onset (58.8%), male (82.4%), unemployed (23.5%), educated
(80.4%), unmarried, and from lower socio-economic status
as compared to the no-subsyndromal mania group. The
no-subsyndromal mania groups had sizable percentages
of person doing business (23.9%), uneducated (19.6%), and
were married (86.9%) [Table 3].
The result showed no significant difference between the
two groups in respect to current age, age at onset, duration
of illness, number of episodes, and average duration of
episode.
DISCUSSION
Socio-demographic and clinical features of this study
broadly coincide with the finding of the literature published
from India.[11-13] Sex difference observed in this study
may be because males suffer more,[14-16] and have greater
severity,[17,18] with tendency for aggressive behavior,[5] and
utilize mental health services more.[18] In Indian setup,
sex differences could also be due to socio-cultural factors
and stigma associated with females availing mental health
service. The familys occupational and economic status
observed in this study is in keeping with traditional Indian
socio-cultural agrarian background. A greater number
of educated patients reflect increased awareness and
better identification of the illness, and thus seeking help.
Interestingly our study found that 45% of patients had a
family history of affective illness either in first and/or seconddegree relative/s. This finding indicates the familial nature
of bipolar disorder,[19] a more severe form,[20] associated
with multiple episodes,[21] and early age at onset.
Frequency of depressive and manic symptoms
Most common manic symptoms observed were decreased,
increased verbal activity, hostility, increased motor activity,
and elevated mood which are comparable to findings
Indian Journal of Psychiatry 52(4), Oct-Dec 2010

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Ram and Ram: Sub syndromal mania in bipolar disorder

stabilizer used for prophylaxis.[24]

Table 1: Sociodemographic variables

Variables

Age at onset
<30
>30
Sex
Male
Female
Occupation
Unemployed
Service
Farmer
Housewife
Student
Business
Education
Uneducated
Primary
M-I level
Gr-PGr
Residence
Rural
Urban
Marriage
Unmarried
Married
SES
Low
Middle
Type of family
Nuclear
Joint
Family history
Absent
Present

With subsyndromal
mania N=51

Without subsyndromal
mania N=46

30
21

58.8
41.2

22
24

47.8
52.8

42
9

82.4
17.6

32
14

69.6
30.4

12
7
9
11
6
6

23.5
13.7
17.6
21.6
11.8
11.8

3
5
11
8
8
11

6.9
10.9
23.9
17.4
17.4
23.9

1
7
41
2

1.9
13.7
80.4
3.9

9
1
30
6

19.6
2.2
65.2
13.0

29
22

56.9
43.1

28
18

60.9
39.1

14
37

27.5
72.5

6
32

13.1
69.6

30
21

58.8
41.2

20
26

43.5
56.5

14
37

27.5
72.5

14
32

30.4
69.6

26
25

50.9
49.1

24
22

52.2
47.8

Table 2: Diagnosis of subsyndromal mania

Variables

Patient Group (N=100)

Subsyndromal mania (score 1-4 on BMRS)

No subsyndromal mania (score 0 on BMRS)

51
49

51
49

Table 3: Correlation of subsyndromal symptoms

Variables

With
subsyndromal
mania N=51

Without
subsyndromal
mania N=46

Out of all the patients, 51% had sub-syndromal manic

symptoms in this study. Though few studies have failed to
show any sub-syndromal symptoms in bipolar disorder in
remission,[6] other studies have found such symptoms in up
to 70% of the patients.[4] Such discrepancy may be related
to methodology and to the scales used for assessment.
Keller et al.[25] observed that these symptoms were due to
inadequate doses of prophylactic medication (Lithium),
while Goodnick et al.[26] found them to be independent of
prophylactic medication.
Khanna et al.[27] found that in India recurrent manic pattern is
more prevalent than typical bipolarity. Ram and Mathew[12]
(1993) found that their patients had positive family history
in up to 50% of cases, 53.3% having severe episode(s),
and relatively unfavorable treatment response and with a
tendency to have multiple episodes.
The patients with sub-syndrome tend to have early age at
onset. They are more often male, unemployed, educated,
unmarried, urban based, and from a joint family and
lower socioeconomic status, and with a family history
of affective illness. These variables are often reported to
associate unfavorable outcome in bipolar disorder. Baur
et al.[28,29] (2009) found that subsyndromal symptoms may
preclude full-time responsibilities outside the home and
suggested to incorporate these symptoms as outcome
measure.
Group difference between patients with and without
sub-syndromal
This study revealed no significant difference between
those with and without sub-syndromal status, though there
were relatively more patients with early age of onset, total
duration in the sub-syndromal manic group. Harrow et al,[25]
found such a relation after 6 months of an index episode.
Exclusion of patient with comorbid disorder, that is known
to be associated with subsyndrome,[30] may also result in
such observations. The heterogeneous nature of the illness
and combined effect of multiple factors may be associated
with such symptoms.

observed in western countries.[2,22,23]

On the basis of the above findings following conclusions

can be drawn that sub-syndromal symptoms are common
in patients with bipolar disorder and does not seem to
be related to current age, age at onset, illness duration,
number of episode and duration of illness.[31] This result may
be more relevant to patient attending psychiatric hospital
at a tertiary centre for follow up probably after treatment of
severe episode of illness.

Common side effects observed in this study were tremor,

difficulty in concentration, sedation, and orthostatic
giddiness. These are well-known side effect of mood

The cross sectional study design, the exclusion of premorbid

temperament / personalities and psychosocial factor as part
of assessment are some of the limitations of this study.

Age
Age at onset
Total duration
No. of episode
Duration episode

SD

SD

31.4
27.7
6.7
3.0
2.2

+ 9.49
+ 9.13
+ 4.17
+ 1.26
+ 1.26

31.7
24.0
7.9
2.0
2.0

+ 11.18
+ 9.43
+ 6.61
+ 1.12
+ 1.12

0.133
0.385
1.030
1.258
0.942

NS
NS
NS
NS
NS

Indian Journal of Psychiatry 52(4), Oct-Dec 2010

369

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Ram and Ram: Sub syndromal mania in bipolar disorder

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Source of Support: Nil, Conflict of Interest: None declared

Indian Journal of Psychiatry 52(4), Oct-Dec 2010