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ORIGINAL PAPER
Cross-national prevalence and cultural correlates of bipolar I
disorder
Kaja R. Johnson •Sheri L. Johnson
Received: 10 May 2013 / Accepted: 17 November 2013 / Published online: 4 December 2013
ÓSpringer-Verlag Berlin Heidelberg 2013
Abstract
Purpose Bipolar disorder has been consistently related to
heightened sensitivity to reward. Greater reward sensitivity
predicts the onset of disorder, a more severe course, and
conversion from milder to severe forms. No studies con-
sider whether cultural factors related to reward sensitivity
influence the course of bipolar disorder. This study exam-
ines the relationship of reward-relevant cultural values to
global prevalence rates of bipolar I disorder.
Methods Lifetime prevalence of bipolar I disorder for 17
countries was drawn from epidemiological studies that
used structured diagnostic interviews of large community
samples. Bivariate correlations were used to assess the
relationship of bipolar disorder prevalence with national
scores on four reward-relevant cultural dimensions (Power
Distance, Individualism, Long-Term Orientation, and Per-
formance Orientation).
Results The prevalence of bipolar I disorder was corre-
lated in the predicted manner with Power Distance and
Individualism, and with Long-Term Orientation and Per-
formance Orientation after outliers were removed.
Conclusions Findings provide evidence for a cultural
model of reward sensitivity in bipolar disorder.
Keywords Bipolar disorder Culture Prevalence
Cross-national Reward sensitivity
Cross-national prevalence and cultural correlates
of bipolar disorder
Bipolar disorder is defined by episodes of abnormally and
persistently elevated, expansive, or irritable mood (i.e.,
mania and hypomania). The population suffers from high
rates of recurrence, suicidality, and hospitalization, and
bipolar disorder has been named as the ninth leading cause
of disability in the world [1]. Recent estimates from global
population surveys reveal rates of bipolar disorder as high
as 4–6 % in adults when broad diagnostic criteria are
applied [2–5]. Using the same standardized interview,
though, the lifetime national prevalence of DSM-IV diag-
noses of bipolar disorder varies widely across countries
from 0.1 to over 4 % [6]. There is a need to improve our
understanding of the factors that contribute differentially to
risk for this disorder.
Many studies have found support for the reward system
model of bipolar disorder [7]. The reward system is
believed to regulate behavior that is directed toward goals.
Inputs to the reward system are environmental stimuli that
serve as cues or elicitations for goal-directed behavior.
Outputs of this system are the manifestations of heightened
activity of the system, such as high arousal positive affect
[8], sociability, increased incentive motivation, goal-set-
ting, excitement, motor activity [9], and confidence [10].
The strong overlap between these outputs and the symp-
toms of bipolar disorder was the base for hypotheses that
heightened activity of the reward system could produce
manic symptoms.
High reward sensitivity should be reflected in greater
reward system output. Pollen sensitivity is an analogue.
Histamine reactions (output) vary depending on the aller-
gen exposure (input) and the individual’s sensitivity to the
allergen. In the case of bipolar disorder, people endorse
K. R. Johnson (&)S. L. Johnson
University of California, Berkeley, 2205 Tolman Hall, Berkeley,
CA 94720, USA
e-mail: kjohnson@berkeley.edu
123
Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117
DOI 10.1007/s00127-013-0797-5
elevated reward sensitivity on self-report scales and show
enhanced psychophysiological responses to reward-rele-
vant stimuli [11]. High reward sensitivity predicts the onset
of bipolar spectrum disorders, conversion to more severe
forms of the disorder, and a more severe course of mania in
bipolar I [11–13]. Clarifying the inputs to the reward sys-
tem would inform prevention efforts.
In this study, we consider the idea that cultural inputs
contribute to heightened output activity of the reward
system. Several findings suggest that environmental inputs
amplify activity of the reward system. For example, life
events involving goal attainment (e.g., getting a new job)
can trigger increases in manic symptoms in bipolar I dis-
order [14,15] and hypomanic symptoms in bipolar spec-
trum disorders [16]. In the framework of Bronfenbrenner’s
widely recognized model of environmental influences on
the individual, these triggers can be conceptualized as
forces in the proximal environment [17]. Reward-relevant
triggers in the distal environments, or societal and cultural
levels, have been hypothesized of bipolar disorder [18], but
not yet empirically applied. One study showed that levels
of cultural collectivism buffered the effect of genetic sus-
ceptibility to anxiety and mood disorders, including bipolar
disorder [19]. However, this study was limited in its ability
to specify cultural correlates of the particular disorders.
Given the substantial variance in global prevalence of
bipolar disorder and the centrality of the reward system to
bipolar disorder, we consider how four reward-relevant
cultural dimensions may contribute to its development.
Cultural inputs to the reward system
Reward-relevant dimensions may shape how richly a
society provides opportunities for reward pursuit, and how
much individuals within that society are encouraged to
pursue those rewards. These dimensions, then, may shape
the inputs to the reward system, and thereby modulate the
activity of this system for individuals living in a given
cultural context. Four cultural dimensions relevant for
striving for rewards and goals have been well-validated: (1)
Power Distance, defined as the degree of power inequality
in a society; (2) Individualism–Collectivism, or the degree
to which independence or interdependence is stressed in a
society; (3) Short- versus Long-Term Orientation, which
describes the societal emphasis placed on future-oriented
goals and delayed gratification; and (4) Performance Ori-
entation, defined by the extent to which a society values
and rewards performance improvement [20,21].
Power Distance may be less obviously associated with
reward compared to the other dimensions, but it is highly
relevant in the study of bipolar disorder. It is helpful to
consider Power Distance as an index of a cultural valuation
of a specific type of reward, namely power. In low Power
Distance countries, power is not concentrated into a few
high ranking individuals, but distributed more equally and
is, therefore, more accessible to the mass. In his study of
Power Distance, Hofstede theorized that individuals with
‘‘partly satisfied’’ power strivings tend to further strive to
maintain or increase that power [20]. It follows, then, that
in low Power Distance countries where more individuals
experience power, a greater number of people will also
experience further power strivings. This corresponds to
findings across multiples samples that mania risk (defined
by lifetime experiences of subsyndromal manic symptoms)
correlates with a heightened motivation to attain power
[22]. We hypothesize that prevalence of bipolar disorder
will be elevated in low Power Distance national cultures.
Cultures that might promote greater activity of the
reward system are those that value initiative and achieve-
ment (high Individualism), excellence and status (high
Performance Orientation), and gratification and quick
results (Short-Term Orientation). We therefore also
hypothesize that the prevalence of bipolar disorder will be
higher in nations with these characteristics.
Methods
Estimates of national lifetime prevalence of bipolar I dis-
order were obtained from several published epidemiologi-
cal studies. The first was the World Mental Health Survey
Initiative, which provided rates for nine countries [6]. The
second was the Cross-National Collaborative Group epi-
demiological study, which provided rates for three coun-
tries [23]. Other published epidemiological studies were
used to provide estimates for the Netherlands [24], Ger-
many [25], Hungary [26], Ethiopia [27], and Nigeria [28].
Where multiple prevalence estimates were available for the
same country, we used the most recently available esti-
mates. All studies included large community samples.
Lifetime prevalence rates and study details for each
country are provided in Table 1.
Bipolar diagnoses
Bipolar I disorder is defined in eachstudy by the presence of at
least one lifetime episode of mania. Mania is a distinct period
of abnormally and persistently elevated, expansive, or irrita-
ble mood [29]. It must be accompanied by three of the fol-
lowing manic symptoms (or four with irritable mood): inflated
self-esteem, decreased need for sleep, hyper-talkativeness,
flight of ideas or subjective experience that thoughts are rac-
ing, distractibility, increase in goal-directed activity or psy-
chomotor agitation, and excessive involvement in pleasurable
activities that have a high potential for painful consequences.
1112 Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117
123
Although the epidemiological studies used in the current
study defined mania using various editions of the diag-
nostic and statistical manual (DSM), these definitions are
highly parallel across iterations. There is only one excep-
tion: the specific criterion for mania duration (1 week or
any duration if hospitalization is required) was included in
DSM-III and DSM-IV, but not in DSM-III-R. The DSM-
III-R was used in assessing the samples from the Nether-
lands and Hungary.
Diagnostic interviews in each study were widely used,
well validated, and designed for use in epidemiological
psychiatric research. These included the World Mental
Health Survey Initiative version of the Composite Inter-
national Diagnostic Interview (CIDI) [30], the Munich-
Composite International Diagnostic Interview (M-CIDI)
[31], and the National Institute of Mental Health Diag-
nostic Interview Schedule (DIS) [32–34]. The CIDI is the
most widely used for international epidemiological studies
of psychiatric illness and has been validated against the
Structured Clinical Interview for DSM-IV [35,36]. The
M-CIDI is an adapted (and closely parallel) version of the
CIDI. It covers a broader range of diagnoses and uses
memory aids to improve participant recall. The M-CIDI
has been validated in clinical and community samples and
shows good test–retest reliability [37–39]. The DIS relies
on the same mania criteria as the CIDI; the two interviews
differ only in that the DIS includes impairment criteria in
diagnoses, unlike the CIDI. All interviews are semi-struc-
tured with detailed probes concerning each psychiatric
syndrome, functional impairment, and medical comorbid-
ities. Diagnoses were derived via computer algorithm, and
all interviewers were highly trained to establish reliability
before data were collected.
Cultural dimensions
National scores for Power Distance, Individualism, and
Long-Term Orientation were drawn from research by
Hofstede [20] and for Performance Orientation from the
work of House and colleagues [21]. All scores were based
on aggregate scores across large samples (about 88,000
respondents to the Hofstede survey and more than 17,000
respondents to the House survey). The Hofstede scores
were based on responses of IBM employees and the House
scores were based on surveys of employees in various
industries. All four scales have attained strong support as
statistically independent of each other [40–42].
Hofstede’s cultural dimensions have been validated in
numerous cross-cultural studies across more than 50
countries and groups and are considered a gold standard for
Table 1 Lifetime prevalence rates of bipolar I disorder in community samples of adults and survey sample characteristics
Survey References Diagnostic interview Country Age (years) Sample size (no.) Lifetime
prevalence (%)
Response
rate (%)
Part 1 Part 2
WMHSI Merikangas et al. [6] CIDI/DSM-IV Brazil C18 5,037 2,942 0.9 81.3
China C18 7,134 2,476 0.3 80.0
Colombia 18–65 4,426 2,381 0.7 87.7
India C18 2,992 1,373 0 98.8
Japan C20 3,417 1,305 0.1 59.2
Lebanon C18 2,857 1,031 0.4 70.0
Mexico 18–65 5,782 2,362 0.7 76.6
New Zealand C16 12,790 7,312 1.0 73.3
United States C18 9,282 5,692 1.0 70.9
CNCG Weissman et al. [23] DIS/DSM-III Taiwan C18 11,004* – 0.3 90.0
South Korea C18 5,100* – 0.4 83.0
Canada C18 3,258* – 0.6 72.0
EDSP Wittchen et al. [25] M-CIDI/DSM-IV Germany 18–24 3,021* 1.4 71.0
HEP Sza
´do
´czky et al. [26] DIS/DSM-III-R Hungary 18–64 2,953 – 1.5 85.0
NEMESIS Ten Have et al. [24] CIDI/DSM-III-R Netherlands 18–64 7,076* – 1.3 64.0
BRHP Negash et al. [27] CIDI/DSM-IV Ethiopia 15–49 68,378* – 0.5 82.2
NSMHW Gureje et al. [28] CIDI/DSM-IV Nigeria C18 4,984 1,682 0 79.9
WMHSI World mental health survey initiative, CNCG cross-national collaborative group, EDSP early developmental stages of psychopathology,
HEP Hungary epidemiology program, NEMESIS The Netherlands mental health survey and incidence study, BRHP Butajira rural health
program, NSMHW Nigerian survey of mental health and well-being, CIDI composite international diagnostic interview, DIS diagnostic interview
schedule, DSM diagnostic and statistical manual, M-CIDI Munich-composite international diagnostic interview, dashes not applicable
* Studies in these countries used a multistage sampling design, but numbers reported in the original papers represent totals
Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117 1113
123
research on cultural values [20,41]. In demonstrations of
their construct validity, these scales have been correlated
with economic, geographic, and demographic indicators
[20]. The Performance Orientation scale has been validated
against the Hofstede scales and other well-established
cultural value dimensions [43], as well as outcomes on the
cross-national World Values Survey [44] and objective
measures of human behavior collected by agencies of the
United Nations (as cited in House, 2004).
Analytic method
Alpha was set to 0.05, and two-tailed tests were used. All
analyses were conducted using version 20 of SPSS.
To test hypotheses, bivariate correlations of lifetime
prevalence of bipolar I disorder and the four cultural value
dimensions were assessed. Case diagnostic methods were
used to determine the presence of outliers in four linear
regressions of the cultural value dimensions on lifetime
prevalence of bipolar I disorder (defined by standardized
residual cutoff scores [2 or Cook’s distance [4/n). Where
outliers were identified, relationships were reanalyzed
without outliers to assess whether correlations significantly
changed.
Although findings regarding the prevalence of bipolar
disorder and socioeconomic status have not been consistent
[45,46], additional analyses were conducted to assess
whether controlling for national income level changed the
relationship between prevalence and cultural value scores.
National income classifications (e.g., low, lower middle,
upper middle, high) were obtained from the World Bank
Group [47]. Ethiopia, India, and Nigeria were classified as
low-income countries; China, Colombia, and Taiwan were
lower middle countries; Brazil, Hungary, Lebanon, Mex-
ico, and South Korea were upper middle countries; and
Canada, Germany, Japan, the Netherlands, New Zealand,
and the United States were high-income countries. First,
bivariate correlations were assessed to determine if income
level was related to (1) bipolar I prevalence, and (2) the
four cultural value dimensions. Then, linear regressions
were used to test the independent effects of income level
and the cultural value dimensions (entered as independent
variables) on bipolar I disorder prevalence (entered as the
dependent variable).
Results
As a test of hypotheses, bivariate correlations were con-
ducted to examine how each of the four cultural value
scales related to the prevalence rates of bipolar I disorder.
As hypothesized, higher prevalence rates of bipolar I dis-
order were associated with lower Power Distance (r=-
0.68, df =14, p\0.01) and higher Individualism
(r=0.67, df =14, p\0.01). Long-Term Orientation
appeared unrelated to the prevalence of bipolar I disorder
(r=-0.41, df =10, p=0.18). Performance Orientation
was only marginally significant but related to prevalence in
the predicted direction (r=0.50, df =13, p=0.06).
Figure 1shows these correlations graphically.
Outlier analyses for the regression of Power Distance on
bipolar I prevalence showed that New Zealand had a large
influence (Cook’s D[4/n) and that Japan had standardized
residuals [2. In the regression of Individualism on preva-
lence, Hungary and India had large standardized residuals.
Nigeria had a large influence and large standardized residuals
in the regression of Long-Term Orientation. The Netherlands
had large standardized residuals in the regression of Perfor-
mance Orientation. When bivariate correlations were re-
computed without these identified outliers, all four cultural
dimensions related significantly in the expected direction to
bipolar I disorder prevalence (Power Distance r=-0.78,
df =12, p\0.01; Individualism r=0.77, df =12,
p\0.01; Long-Term Orientation r=-0.66, df =9,
p\0.03; Performance Orientation r=0.61, df =12,
p\0.03).
National income level was correlated with bipolar I prev-
alence (r=0.59, df =15, p\0.02) and two cultural
dimensions: Power Distance (r=-0.69, df =14, p\0.01)
and Individualism (r=0.71, df =14, p\0.01). Two par-
allel linear regression models were conducted to examine the
effects of Power Distance and Individualism on bipolar I
prevalenceafter accounting for nationalincome level. Neither
Power Distance (b=-0.01, t=-1.79, p=0.10), nor
Individualism (b=0.01, t=1.62, p=0.13) were signifi-
cantly related to bipolar I prevalence after controlling for
national income.
Discussion
The goal of the current study was to examine how reward-
relevant cultural values relate to national prevalence rates
of bipolar I disorder. We hypothesized that ‘‘maniatrophic’’
cultures (P. Blanc, personal communication, September 30,
2013), or cultures that shape a reward-rich environment by
placing a high value on the individual pursuit of reward and
providing opportunities to do so, would be related to
greater prevalence rates. Four well-established cultural
dimensions relevant to reward were examined. Prevalence
rates were drawn from studies using large community
samples and well-validated, reliable diagnostic interviews.
The sampled countries represent diverse geographic and
economic areas across six continents. As hypothesized,
lower Power Distance and higher Individualism were cor-
related with higher prevalence rates of bipolar I disorder.
1114 Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117
123
Outliers were important to consider. Lower Long-Term
Orientation and higher Performance Orientation were only
significantly related to higher prevalence after respectively
removing Nigeria and the Netherlands from regression
models. Nigeria’s Long-Term Orientation score was rela-
tively low compared to other countries, as is the case
among African countries, which score at or below 25 on
this scale. There is some evidence suggesting that Short-
Term Orientation in African countries may be qualitatively
different from the same in other countries [20]. Given the
relatively high prevalence of bipolar I disorder in the
Netherlands, Performance Orientation is expected to be
higher, but it is possible that the prevalence estimate is
somewhat inflated. Whereas diagnostic criteria for mania
were parallel across most samples, prevalence estimates for
the Netherlands and Hungary were based on DSM-III-R
criteria, which used a broader criterion for mania duration.
Perhaps relatedly, their prevalence rates were much higher
than other countries (1.3 and 1.5 %, respectively).
Analyses of national income revealed no associations
with Long-Term Orientation and Performance Orientation,
but income did seem to account for a portion of the effects
of Power Distance and Individualism, suggesting that
income levels may be systematically related to prevalence
Fig. 1 Correlations of cultural dimensions with cross-national life-
time prevalence of bipolar I disorder across 17 countries. Power
Distance and Individualism scores were available for 16 countries.
Long-Term Orientation was available for 12 countries. Performance
Orientation scores were available for 15 countries. A total of 16
countries was represented across all dimensions. Performance Orien-
tation scale range was 1–7. Long-Term Orientation scale range was
1–100; however, China was added to the data after country scores
were fixed [20]
Soc Psychiatry Psychiatr Epidemiol (2014) 49:1111–1117 1115
123
of bipolar disorder. Our use of standardized diagnostic
interviews provides more concrete evidence to early stud-
ies demonstrating an association between higher income
and greater bipolar disorder prevalence [48]. Findings also
extend theory regarding income as a correlate of reward
system activity within bipolar disorder [49], and suggest
that this variable be considered in cultural models of
bipolar disorder.
Limitations of this study should be noted. Analyses were
entirely based on responses aggregated into national level
estimates. There is a need to more carefully understand how
distal influences operating at a national level guide specific
attitudes, contexts, and behaviors for individuals. Methodo-
logical limitations includethe small number of countries with
prevalence estimates. Also of note, samples differed in the
maximum age of participants, although most surveys covered
the ages during which bipolar onset would be expected [50].
One exception may be Nigeria, where age of onset for mental
disorder tends to be higher [28]. This may explain the absence
of bipolar cases identified in Nigeria. Greater consistency in
diagnostic assessment must be integrated in future epidemi-
ological studies to address methodological limitations.
Notwithstanding limitations, the large effect sizes
observed here demonstrate how even distal cultural influ-
ences may shape the development of bipolar disorder and
suggest that developing a cross-cultural model of the dis-
order is an appropriate and important next step for bipolar
disorder research. More specifically, future research should
consider how distal influences operating at a national level
guide specific attitudes, contexts, and behaviors for indi-
viduals. Understanding how reward values at a national
level shape individual experiences will help refine clinical
models of how to protect the reward sensitive person with
bipolar disorder living in an overly-activating culture.
In summary, the current study provides one of the first
applications of a cultural model to extend the reward system
model of bipolar disorder and to explain the variation in the
global prevalence of bipolar disorder. The findings suggest
that cultural models may enhance understanding of this
illness.
Acknowledgments The authors thank Dr. Batja Mesquita who is at
the Center for Social and Cultural Psychology at KU Leuven, Bel-
gium for her guidance in identifying relevant literature for this study.
Conflict of interest The authors declare that they have no conflict
of interest.
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