title: Bipolar disorder and socioeconomic status: what is the nature of this relationship?
abstract: BACKGROUND
  In psychiatric literature stretching over a century, there have been glaring discrepancies in the findings describing the relationship between bipolar disorder (BD) and socioeconomic status (SES). Early studies indicated an overall association between manic-depressive illness and higher social class. However, recent epidemiologic studies have failed to find an association between BD and SES. Instead, they report a similar distribution of BD among social classes and educational levels, and in one particular study, a lower family income was reported. The determinants of SES are complex, and the early findings are now interpreted as having been incorrect and stemming from past methodological weaknesses.
  
  
  METHODS
  For this analysis we explored the relationship between SES and BD in a sample of patients who had participated in prior clinical and therapeutic studies. These patients met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BD, required long-term stabilizing treatment, and were assessed in terms of their response to lithium stabilization and a number of other clinical characteristics in accordance with research protocol. Good response to lithium stabilization (LiR) served as a proxy for identifying a subtype of manic-depressive illness, the classical form of BD. Non-responders to stabilizing lithium (LiNR) were considered belonging to other subtypes of bipolar spectrum disorder. The SES of the parents was measured upon entry into treatment using the Hollingshead SES scale, which despite its limitations has been used in psychiatry most widely to determine SES. The groups of LiR and LiNR were compared statistically in terms of SES. The influence of bipolar subtype and gender on SES was investigated.
  
  
  CONCLUSIONS
  A significantly higher SES was associated with the lithium-responsive form (LiR) of BD when compared with patients continuing to relapse despite adequate lithium treatment (representing other types of bipolar spectrum). Our observation suggests that the discrepant literature findings about SES and BD may be better explained by the change in diagnostic practices: early studies describing a positive relationship included mostly classical manic-depressive disorder, while the patients in recent studies have been diagnosed according to much broader criteria, reflecting the era of bipolar spectrum disorder.
authors.affiliation: School of Medicine, Queen's University, Kingston, Ontario K7L 3N6 Canada.
authors.forename: Laeticia
authors.initials: L
authors.lastname: Eid
authors.affiliation: Mood Disorders Centre of Ottawa, Ottawa, Ontario K1G 4G3 Canada.
authors.forename: Katrina
authors.initials: K
authors.lastname: Heim
authors.affiliation: Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia B3H 4R2 Canada.
authors.forename: Sarah
authors.initials: S
authors.lastname: Doucette
authors.affiliation: Mood Disorders Centre of Ottawa, Ottawa, Ontario K1G 4G3 Canada.
authors.forename: Shannon
authors.initials: S
authors.lastname: McCloskey
authors.affiliation: Mood Disorders Centre of Ottawa, Ottawa, Ontario K1G 4G3 Canada ; Department of Psychiatry, University of Calgary, Calgary, Alberta T2N 1N4 Canada.
authors.forename: Anne
authors.initials: A
authors.lastname: Duffy
authors.affiliation: Mood Disorders Centre of Ottawa, Ottawa, Ontario K1G 4G3 Canada ; Department of Psychiatry, University of Toronto, Toronto, Ontario M5S 1A1 Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Grof
keywords: Bipolar disorder; Gender; Lithium response; Longitudinal studies; Socioeconomic status