Decreased core symptoms of mania and utilization of lithium/mood stabilizing anticonvulsants in U.S. bipolar I patients of African vs European ancestry

J Affect Disord. 2020 Jan 1;260:361-365. doi: 10.1016/j.jad.2019.09.022. Epub 2019 Sep 4.


Objective: Misdiagnosis is common in bipolar disorder and disproportionally affects racial and ethnic minorities. There is interest in better understanding the contribution of differential symptomatic illness presentation to misdiagnosis.

Methods: Utilizing the Genetic Association Information Network (GAIN) public database, this study compared clinical phenomenology between bipolar patients of African vs European ancestry (AA = 415 vs EA = 480). The Diagnostic Interview for Genetic Studies (DIGS) was utilized to evaluate symptom endorsement contributing to diagnostic confirmation of bipolar I disorder (BPI) and lifetime medication use.

Results: Elevated/euphoric mood was less endorsed in AA vs EA participants (p = 0.03). During the most severe episode of mania, AA participants, in comparison to EA participants, had a lower sum of manic symptoms (p = 0.006) and a higher rate of hallucinations (p = 0.01). During lifetime psychosis, AA participants, in comparison to EA participants, had a higher lifetime sum of delusions (p = 0.01) and hallucinations (p < 0.0001). AA participants reported lower use of lithium (p < 0.0001) and mood stabilizing anticonvulsants (p = 0.0003).

Conclusions: The differential rate of manic and psychotic symptom endorsement from a semi-structured diagnostic interview may represent differential illness presentation based on biological differences or racial or study biases (e.g. ascertainment). Increased minority recruitment in bipolar research is therefore a necessary future direction.

Limitations: Recall and interviewer bias may affect study results, but are likely diminished by the alignment of symptom endorsement and medication use.

Keywords: Bipolar; Health disparity; Lithium; Psychosis.

Publication types

  • Evaluation Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Anticonvulsants / therapeutic use
  • Antimanic Agents / therapeutic use*
  • Bipolar Disorder / drug therapy
  • Bipolar Disorder / ethnology*
  • Bipolar Disorder / psychology
  • Black People / psychology*
  • Databases, Factual
  • Female
  • Humans
  • Lithium Compounds / therapeutic use
  • Male
  • Middle Aged
  • Patient Acceptance of Health Care / ethnology*
  • Pilot Projects
  • United States
  • White People / psychology*


  • Anticonvulsants
  • Antimanic Agents
  • Lithium Compounds