When I was in medical school, which was not too long ago, bipolar disorder was considered an exotic disease that was easily diagnosed because of its clear-cut features. The disorder was thought to be rare, the province of upper-class, older Caucasians. It generally was associated with a positive prognosis and was believed to have very limited public health significance or scientific relevance that might affect knowledge about other disorders.
In recent years, many of these beliefs have been found to be myths. The definition of bipolar disorder has changed and become more inclusive in the wake of new knowledge. Better diagnostic tools have shown us that this disorder is as common as any other Axis I disorder. It is found with similar prevalence in every ethnic or racial group. It is also often misdiagnosed or underdiagnosed. As a result, individuals are under-treated or never treated.
The burden of this disorder for family members and society is similar to that of schizophrenia. Like schizophrenia, this is a chronic, often relapsing illness, and specialty treatment is needed. While marriage, families, and employment are all relatively static for patients with bipolar disorder, in contrast with schizophrenia, the correct diagnosis for bipolar disorder may not be made until more than a decade after first presentation of symptoms. Initial treatment is often administered by nonspecialists, and years of suffering may occur before the appropriate treatment is developed.
This issue of Psychiatric Annals will review the effects of some persisting myths that may contribute to the continuing poor quality of services for many individuals with bipolar disorder. Fortunately, effective treatments have been developed. Unfortunately, they often are not available and are ineffective in the practicing community. The articles in this issue were developed with the intent of providing the reader with an appreciation of the complexity of this disorder.
Bipolar disorder probably has the highest heritability of any Axis I psychiatric disorder. Only recently, however, have genetic markers begun to emerge. In addition, ethnic minorities are often misdiagnosed and under-treated. The articles by Drs. John Nurnburger and Tatiana Faroud on genetics, and by Dr. Tony Strickland and myself on racial and cultural issues, review some of these approaches to the disorder, with the aim of Moirning the reader about emerging findings. Studying the genetic, phenomenological, and cultural influences associated with bipolar disorder will lead to a better understanding of it.
One of the biggest challenges in treating bipolar disorder may be in understanding how comorbidities increase the complexity of treatment. General medical comorbidities are common and should be studied, because patients with comorbid disorders may be at increased risk of life-threatening disorders. Substance abuse, for example, is extremely common among patients with bipolar disorder and affects both the diagnosis
and course. Migraine also appears to be much more common among those with bipolar disorder. However, little research has been done in either area. These issues are discussed in the articles by Dr. Nancy Low and colleagues and by Dr. Walter Bland and myself, in an effort to to determine the effects these comorbidities have on treatment and diagnosis.
Above all, I believe more must be done to expand the knowledge base for the providers of psychiatric treatment for patients with bipolar disorder. It is my hope that these articles will serve as a helpful resource.