Psychiatric Annals

Guest Editorial 

This Issue: Complexities of Care in Bipolar Disorder

Martha Sajatovic, MD

Abstract

It is a great pleasure to guest edit this issue of Psychiatric Annals, which focuses on the real-world complexities and challenges faced by individuals with bipolar disorder, and by their partners, families, and clinicians.

Although there have been real and impressive advances in both pharmacological and behavioral treatments that can improve health outcomes among people with bipolar disorder, it is clear that the literature evidence-base, particularly medication treatment randomized controlled trials (RCTs), do not specifically inform treatment choices for all patients with bipolar disorder.

In many RCTs, people with comorbid conditions such as substance use disorders and significant medical comorbidity are specifically excluded from trial enrollment. Similarly, pregnant or lactating women are generally not included in most RCTs.

In contrast to the selectivity seen in RCTs, clinicians in real-world settings are tasked with the messy business of helping people with multiple morbidities and challenging circumstances to get symptom relief and ultimately achieve recovery. This can be a daunting challenge.

Fortunately, there is growing awareness that complexity is part-and-parcel of living with bipolar disorder. There is an emerging body of literature that addresses this complexity head-on. This special issue features the work of four experts in bipolar disorder research who share their insights on key areas that complicate health outcomes and recovery among people with bipolar disorder.

Erin E. Michalak, PhD, and colleagues from the University of British Columbia address the important issue of recovery from the perspective of the individual living with bipolar disorder. As the authors point out, the notion that bipolar disorder is a severe mental illness with a relatively poor prognosis may set the stage for a bleak view that offers little hope for “recovery.” The implications of this message for people newly diagnosed can be profound1 and may impact key predictors of treatment response such as treatment adherence, treatment alliance, or whether the individual engages with psychiatric care at all. Michalak and colleagues present findings from recent qualitative and community-based participatory research that provide potential for deeper insights into understanding of recovery for people with bipolar disorder.

David E. Kemp, MD, MS, and Jinbo Fan, PhD, review the issue of cardiometabolic health in bipolar disorder. Metabolic syndrome occurs twice as often in those with bipolar disorder as in the general population and predisposes patients to cardiovascular disease, diabetes, and early mortality.2 Kemp and Fan review the scope of cardiometabolic health concerns in bipolar disorder, pathophysiological correlates linking metabolic dysregulation and mood, and potential genetic vulnerabilities. They discuss novel treatment approaches that target metabolic health among individuals with bipolar disorder.

Wendy Marsh, MD, MS, and Adele Viguera, MD, MPH, review the literature on the management of bipolar disorder in women who are pregnant or postpartum. Given that pregnancy appears not to be protective against bipolar disorder3 and postpartum is a time of potentially increased risk for mood relapse,4 patients and clinicians need to be well-aware of the risk vs. benefits of treatment.

Bryan K. Tolliver, MD, PhD, and Karen J. Hartwell, MD, discuss bipolar disorder complicated by co-occurring substance use disorder (SUD). It has been reported that 50% to 60% of people with bipolar disorder will develop at least one SUD in their lifetime, and bipolar disorder is the Axis I diagnosis most commonly associated with a comorbid SUD.5–9 SUD and bipolar disorder share a number of characteristics that present challenges for diagnosis and clinical management. The authors provide a number of pragmatic recommendations based upon emerging lines of evidence.

Taken together, this collection of papers illustrates the range of complexity which exists for patients, families, and clinicians managing bipolar disorder. While the reviews are encouraging in…

It is a great pleasure to guest edit this issue of Psychiatric Annals, which focuses on the real-world complexities and challenges faced by individuals with bipolar disorder, and by their partners, families, and clinicians.

Although there have been real and impressive advances in both pharmacological and behavioral treatments that can improve health outcomes among people with bipolar disorder, it is clear that the literature evidence-base, particularly medication treatment randomized controlled trials (RCTs), do not specifically inform treatment choices for all patients with bipolar disorder.

In many RCTs, people with comorbid conditions such as substance use disorders and significant medical comorbidity are specifically excluded from trial enrollment. Similarly, pregnant or lactating women are generally not included in most RCTs.

In contrast to the selectivity seen in RCTs, clinicians in real-world settings are tasked with the messy business of helping people with multiple morbidities and challenging circumstances to get symptom relief and ultimately achieve recovery. This can be a daunting challenge.

Fortunately, there is growing awareness that complexity is part-and-parcel of living with bipolar disorder. There is an emerging body of literature that addresses this complexity head-on. This special issue features the work of four experts in bipolar disorder research who share their insights on key areas that complicate health outcomes and recovery among people with bipolar disorder.

Erin E. Michalak, PhD, and colleagues from the University of British Columbia address the important issue of recovery from the perspective of the individual living with bipolar disorder. As the authors point out, the notion that bipolar disorder is a severe mental illness with a relatively poor prognosis may set the stage for a bleak view that offers little hope for “recovery.” The implications of this message for people newly diagnosed can be profound1 and may impact key predictors of treatment response such as treatment adherence, treatment alliance, or whether the individual engages with psychiatric care at all. Michalak and colleagues present findings from recent qualitative and community-based participatory research that provide potential for deeper insights into understanding of recovery for people with bipolar disorder.

David E. Kemp, MD, MS, and Jinbo Fan, PhD, review the issue of cardiometabolic health in bipolar disorder. Metabolic syndrome occurs twice as often in those with bipolar disorder as in the general population and predisposes patients to cardiovascular disease, diabetes, and early mortality.2 Kemp and Fan review the scope of cardiometabolic health concerns in bipolar disorder, pathophysiological correlates linking metabolic dysregulation and mood, and potential genetic vulnerabilities. They discuss novel treatment approaches that target metabolic health among individuals with bipolar disorder.

Wendy Marsh, MD, MS, and Adele Viguera, MD, MPH, review the literature on the management of bipolar disorder in women who are pregnant or postpartum. Given that pregnancy appears not to be protective against bipolar disorder3 and postpartum is a time of potentially increased risk for mood relapse,4 patients and clinicians need to be well-aware of the risk vs. benefits of treatment.

Bryan K. Tolliver, MD, PhD, and Karen J. Hartwell, MD, discuss bipolar disorder complicated by co-occurring substance use disorder (SUD). It has been reported that 50% to 60% of people with bipolar disorder will develop at least one SUD in their lifetime, and bipolar disorder is the Axis I diagnosis most commonly associated with a comorbid SUD.5–9 SUD and bipolar disorder share a number of characteristics that present challenges for diagnosis and clinical management. The authors provide a number of pragmatic recommendations based upon emerging lines of evidence.

Taken together, this collection of papers illustrates the range of complexity which exists for patients, families, and clinicians managing bipolar disorder. While the reviews are encouraging in that promising new directions and research are emerging, it is also clear that there is much to be done and new research and information is needed so that treatment decisions can truly be individualized depending on comorbidity and life circumstances.

References

  1. Michalak E, Maxwell V. Experiences and understandings of diagnosis: lived-experience perspectives. In: Murray G. A Critical Introduction to DSM. Hauppauge, NY: Nova Science; 2011.
  2. McIntyre RS, Danilewitz M, Liauw SS, et al. Bipolar disorder and metabolic syndrome: an international perspective. J Affect Disord. 2010;126(3):366–387. doi:10.1016/j.jad.2010.04.012 [CrossRef]
  3. Viguera AC, Whitfield T, Baldessarini RJ, et al. Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry. 2007;164(12):1817–1824. doi:10.1176/appi.ajp.2007.06101639 [CrossRef]
  4. Harlow BL, Vitonis AF, Sparen P, Cnattingius S, Joffe H, Hultman CM. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42–48. doi:10.1001/archpsyc.64.1.42 [CrossRef]
  5. Reiger DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA. 1990;264(19):2511–2518. doi:10.1001/jama.1990.03450190043026 [CrossRef]
  6. Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry. 1997;54(4):313–321. doi:10.1001/archpsyc.1997.01830160031005 [CrossRef]
  7. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61(8):807–816. doi:10.1001/archpsyc.61.8.807 [CrossRef]
  8. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States. Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830–842. doi:10.1001/archpsyc.64.7.830 [CrossRef]
  9. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2007;64(5):543–552. doi:10.1001/archpsyc.64.5.543 [CrossRef]
Authors

Martha Sajatovic, MD, is Professor of Psychiatry at Case Western Reserve University School of Medicine in Cleveland, Ohio. She is a researcher, educator, and clinician who has devoted herself to the study and treatment of traditionally hard-to-treat populations with serious mental illness. Dr. Sajatovic is Director of Geropsychiatry at University Hospitals Case Medical Center (UHCMC) and holds the Willard Brown Chair in Neurological Outcomes at UHCMC/Case Western Reserve University School of Medicine. Dr. Sajatovic has been a recipient of the Exemplary Psychiatrist Award bestowed by the National Alliance for the Mentally Ill (NAMI), and was a Depression and Bipolar Support Alliance (DBSA) 2006 Gerald Klerman Young Investigator Award winner.

10.3928/00485713-20120507-03

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