Is there a relationship between age at menarche and clinical and temperamental characteristics in bipolar disorder?
Erenköy Mental and Neurological Disease Training and Research Hospital, Department of Psychiatry Istanbul, Turkey
Adnan Menderes University, Department of Psychiatry Aydın, Turkey
Erenköy Mental and Neurological Disease Training and Research Hospital, Department of Psychiatry Istanbul, TurkeyElif Tatlıdil Yaylacı, MD
Erenköy Mental and Neurological Disease Training and Research Hospital, Department of Psychiatry Istanbul, Turkey
BACKGROUND: This study investigated whether age at menarche in women with bipolar disorder (BD) is different from that in healthy women and if there is a relationship between age at menarche and clinical and temperamental characteristics of BD.
METHODS: We consecutively evaluated 126 euthymic women diagnosed with BD according to DSM-IV. The healthy control group comprised 100 individuals of similar mean age and socioeconomic level. After the diagnostic interview, BD patients completed the Mood Disorders Diagnosis and Follow-Up Form and Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire.
RESULTS: Age at menarche in BD patients was similar to that in controls. A strong inverse correlation was found between age at menarche and total duration of depressive episodes (r = -0.532). In BD patients, an inverse correlation has been found between age at menarche and depressive and cyclothymic temperament scores (r = -0.384 and r = -0.421). However, a strong correlation has been found between age at menarche and irritable temperament scores (r = 0.488).
CONCLUSIONS: Age at menarche is associated with the clinical course of BD. Moreover, age at menarche seems to be associated with traits related to mood.
KEYWORDS: age at menarche, affective temperament, bipolar disorder
ANNALS OF CLINICAL PSYCHIATRY 2013;25(2):121-124
Menarche is one of the most important events in a woman’s life. Emotional and social factors affecting the age at menarche have not been adequately investigated. Early menarche—defined as before age 10—is associated with adverse psychosocial consequences such as low educational level, early pregnancy, and increased delinquent behavior.1 Among a group of women age 17 to 30, those who experienced early menarche show a 2-fold higher allostatic load.2 Therefore, its inclusion as a risk factor in bipolar disorder (BD) is important to aid protective and preventive efforts. The effects of chronic stress in general health converge on the concept of allostatic load.3 Allostatic load is the bodily “wear and tear” that emerges with sustained allostatic states. In BD, allostatic load offers an important clue as to why patients who undergo recurrent mood episodes are perceived as less resilient. Stress- and episode-induced changes in brain regions involved in emotional circuitry may lead to dysfunctional information processing, which would render BD patients more vulnerable to subsequent environmental stressors, mood episodes, and substance abuse.4 Lessening allostatic load would not only alleviate emotional suffering, but also slow the cycle of BD, cognitive decline, physical morbidities, and related mortality.
Approximately one-third of women with BD experience disease onset before menarche and 18% within 1 year of menarche.5 To our knowledge, there are no studies systematically examining age at menarche in BD. The aim of this study is to investigate whether the age at menarche in BD patients is different from that in healthy women and to determine if there is a relationship between the age at menarche and clinical and temperamental characteristics of BD.
In this study, 126 women diagnosed with BD according to DSM-IV and were in remission and referred to our outpatient clinic for routine follow-up were evaluated consecutively. The healthy control group comprised 100 individuals coming from the same geographic regions as the BD patients, had similar mean age and socioeconomic level, and had no history of psychiatric referral, treatment, or psychiatric symptoms.
Structured Clinical Interview for DSM–Axis I Disorders (SCID-I). DSM-IV structured clinical interview form for Axis I disorders, Turkish version.6
Structured Clinical Interview for DSM-Axis I Disorders–nonpatient (SCID-NP). DSM-III-R structured clinical interview form for Axis I disorders for non-patients, Turkish version.7
SKIP-TURK (Mood Disorders Diagnosis and Follow-Up Form). This scale evaluated age at disorder onset, duration of the disorder, age at treatment initiation, history of physical and sexual abuse, academic and social functioning, age at menarche, premenstrual syndrome, type of first mood episode, severity of the episode, postpartum onset, seasonality, depression subtype, psychotic episodes, suicide, hospitalization, duration of the episode, number of episodes, dominant course pattern, acute onset and remission, chronicity and rapid cycling shifts, cigarette smoking, and substance use.8
Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) temperament scale. This scale, developed by Akiskal et al,9 consists of 100 items to determine depressive, cyclothymic, hyperthymic, irritable, and anxious temperament. The individual considers his or her life-time and responds to the items as “yes” or “no”. The Turkish version of the scale has been shown to be valid and reliable.10
The Education Planning Commission of Erenköy Mental Health Training and Research Hospital provided permission to conduct this study. Following the diagnostic interviews (SCID-I and SCID-NP) researchers initiated an open-ended interview with the BD patients in order to complete the SKIP-TURK form. We gathered additional information from the patients’ family for reliability. SKIP-TURK recorded age at menarche, which is defined as the year with regular and consecutive periods.1 The control group was evaluated with the SCID-NP. Next, the controls and patients were asked to fill in the TEMPS-A temperament scale. If the subjects are not sure about an item in TEMPS-A, they are advised to answer “no” and to consider their whole life in their responses.
Parametric variables were compared with t test (because standard deviation [SD] mean was < 0.3) while categorical variables were compared with chi-square test. Pearson correlation test was used for correlation analysis. Statistical significance was set at P < .05 and all tests were 2-tailed.
Mean age of 126 BD patients (35.91±12.53) is similar to that of healthy controls (34.28±10.45; t = 1.3, P = .524). Clinical characteristics of BD patients is outlined in the TABLE.
Clinical features of BD patients
|Age of menarche (mean±SD)
|Age of onset illness (mean±SD)
|Frequency of total episodes (number of episodes/years), (mean±SD)
|Frequency of manic episodes (number of episodes/years), (mean±SD)
|Frequency of depressive episodes (number of episodes/years), (mean±SD)
|Frequency of mixed episodes (number of episodes/years), (mean±SD)
|Duration of total episodes (months), (mean±SD)
|Duration of manic episodes (months), (mean±SD)
|Duration of depressive episodes (months), (mean±SD)
|Duration of mixed episodes (months), (mean±SD)
Comparison of age at menarche between BD patient and controls
Mean age at menarche in BD patients (13.25±1.18) is similar to that of controls (13.86±1.72; t = 1.2, P = .621).
The relationship between age at menarche and clinical characteristics and affective temperaments scores
In BD patients, no relationship was found between age at menarche and age of BD onset, episode severity, and duration of manic, mixed, and total episodes. However, a strong inverse relation was found between age at menarche and total duration of depressive episodes (r = -0.532, P = .008).
In BD patients, an inverse correlation was found between age at menarche and depressive and cyclothymic temperaments scores (r = -0.384, P = .043; r = -0.421, P = .035, respectively). However, a strong correlation has been found between age at menarche and irritable temperament scores (r = 0.488, P = .03).
To our knowledge, this is the first study investigating age at menarche in BD patients. In our study, age at menarche in BD patients was not different from that in healthy women. An important relationship was found between total duration of depressive episodes and age at menarche.
Mean age at menarche in healthy controls is comparable with those found by Ersoy et al11 in Western regions of Turkey in 2004. If frequency of episodes and duration of episodes are taken into account, our BD patients have relatively moderate clinical course. Age at menarche may be a more decisive variable or risk factor in BD patients with more severe clinical course. Strong inverse relationship between age at menarche and total duration of depressive episodes creates the expectation that functioning will be worse in patients who experienced early menarche.
The literature examining age at menarche and psychopathology often evaluate adolescents and focus on frequency of psychopathology or psychopathological symptoms in early menarche. In a birth cohort study in New Zealand, early menarche was associated with anxiety disorders.12 In a birth cohort in England, girls with menarche at age <11.5 were reported to have more depressive symptoms than other adolescents at age 13 and 14.13 In a study of university students in China, depressive symptoms, suicidal ideation, and self-harm behavior was more frequent in the early menarche group than normal or late menarche groups.14 In a birth cohort in Finland, women with late menarche (age ≥16) showed a higher prevalence of depression after age 31.15 This is may be true for unipolar depression because BD onset at age ≥31 would be considered late. This finding is not discordant with our findings. Patients with late onset BD may be considered to have unipolar depression.
The studies carried out so far, including our own, have been retrospective. In the only prospective follow-up study, Black et al16 demonstrated that early menarche predicted depressive symptoms in adolescence and depressive symptoms were more frequent in the early menarche group. Depressive symptoms that emerge in adolescence are risk factors for BD.17 Therefore, depressive symptoms predicted by early menarche and childhood depressive symptoms may be interpreted in favor of future probable BD. Deng et al14 found not only depressive symptoms but also suicidal ideation and self-harm behavior to be more frequent in the early menarche group. This does not contradict the suggestions of Angst et al17 that depressive episodes accompanied by psychomotor agitation are indicators of bipolarity.
On the other hand, these subthreshold states, which do not meet diagnostic criteria of a depressive episode and defined as depressive symptoms in the aforementioned studies, may be related to affective temperament. Similarly, suicidal ideation and self-harm behavior are closely related to some temperament types.18 In the present study, an inverse relationship between age at menarche and cyclothymic temperaments scores was found. Cyclothymic temperament, which is characterized by mood lability, sudden and reactive nature of mood changes, and few skills for regulating negative emotions, is dominant in BD and associated with clinical characteristics of BD.19,20 Especially in child and adolescent BD patients, jittery mood is associated with chronic course.21
In a study of female rhesus monkeys, high aggression, emotional reactivity, and anxiety levels and low level of harmony with other group members predicted delayed puberty.22 In addition, coexistence of such characteristics explains 58% of the variation in age at menarche. These findings are consistent with our results that there is a linear correlation between age at menarche and irritable temperaments score. Available information is not sufficient to comment on this situation.
According to our findings, age at menarche is related to the clinical course of BD. Moreover, age at menarche also seems to be related to traits related to mood. Further studies are required to shed light on this relation. Our findings suggest that neuroendocrine profiles of affective temperaments and BD remain to be discovered.
DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
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- Kapczinski F, Vieta E, Andreazza AC, et al. Allostatic load in bipolar disorder: implications for pathophysiology and treatment. Neurosci Biobehav Rev. 2008;32:675–692.
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- Akiskal HS, Akiskal KK, Haykal RF, et al. TEMPS-A: progress towards validation of a self-rated clinical version of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord. 2005;85(1-2):3–16.
- Vahip S, Kesebir S, Alkan M, et al. Affective temperaments in clinically-well subjects in Turkey: initial psychometric data on the TEMPS-A. J Affect Disord. 2005;85:113–125.
- Ersoy B, Balkan C, Günay T, et al. Effects of different socioeconomic conditions on menarche in Turkish female students. Early Hum Dev. 2004;76:115–125.
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- Herva A, Jokelainen J, Pouta A, et al. Age at menarche and depression at the age of 31 years: finding from the Northern Finland 1966 Birth Cohort Study. J Psychosom Res. 2004;57:359–362.
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- Angst J, Gamma A, Benazzi F, et al. Does psychomotor agitation in major depressive episodes indicate bipolarity? Evidence from the Zurich Study. Eur Arch Psychiatry Clin Neurosci. 2009;259:55–63.
- Skala K, Kapusta ND, Schlaff G, et al. Suicidal ideation and temperament: an investigation among college students. J Affect Disord. 2012;141:399–405.
- Perugi G, Akiskal HS. The soft bipolar spectrum redefined: focus on the cyclothymic anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions. Psychiatr Clin North Am. 2002;25:713–737.
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- Wilson ME, Bounar S, Godfrey J, et al. Social and emotional predictors of the tempo of puberty in female rhesus monkeys. Psychoneuroendocrinology. 2013;38:67–83.
CORRESPONDENCE: Sermin Kesebir, MD Erenköy Mental and Neurological Disease Training and Research Hospital Sinan Ercan Cadessi, N: 29, Kadıköy Istanbul, Turkey E-MAIL: email@example.com
Annals of Clinical Psychiatry ©2013 Frontline Medical Communications Inc.