Psychiatric Annals

Guest Editorial Free

Addressing Unmet Needs in Bipolar Disorder

Holly A. Swartz, MD

Bipolar disorder is a common illness, affecting 2% to 3% of the population worldwide.1 In addition to being prevalent, bipolar disorder is also chronic and disabling. Longitudinal studies show that people with bipolar disorder spend at least half of their lives with mood symptoms, with the depressive phase of the disorder predominating.2 Impairments in cognitive, social, vocational, and interpersonal functioning are the rule rather than the exception.3–6 Elevated risk for suicide7,8 and cardiovascular diseases9 contribute to increased risk for premature mortality.10

Despite being a common disorder, numerous unmet clinical needs persist. Treatments for bipolar disorder, although associated with reductions in symptoms, yield disappointing remission rates. Only about one-quarter of patients treated with bipolar-specific pharmacotherapy achieve remission from acute episodes and remain well for more than 1 year.11 Many treatments used to manage bipolar disorder are associated with significant side-effect burden, requiring both patients and clinicians to engage in a careful evaluation of potential harms as well as benefits,12,13 especially during the perinatal period.14 Bipolar depression remains a uniquely troubling treatment challenge; depression drives most of the morbidity and mortality associated with bipolar disorder15 and yet only four US Food and Drug Administration-approved medications are available to treat this episode-type.

This issue of Psychiatric Annals highlights the challenges that arise in the context of managing bipolar disorder and offers suggestions for addressing them. We present four clinically focused articles that emphasize key issues facing people with bipolar disorder and the clinicians who manage the illness. The first article, “An Update on the Other Cause of Excess Death in Bipolar Disorder: Cardiovascular Disease,” by Dr. Jess G. Fiederowicz calls attention to the alarming finding that people with bipolar disorder have approximately twice the risk of cardiovascular disease and mortality relative to those without bipolar disorder. Mental health providers are challenged to take a more active role in managing their patients' modifiable cardiovascular risk factors to reduce associated morbidity and mortality. The second article, “Determining Patient Candidacy for Antidepressant Use in Bipolar Disorder” by Dr. Joseph F. Goldberg takes a novel approach to addressing the controversial topic of whether it is safe and efficacious to use antidepressant medications to manage bipolar depression. Arguing that these medications are useful in some contexts but not others, Dr. Goldberg proposes using a candidacy model to designate specific patients for whom antidepressant therapy may be appropriate. The information provided in the article can inform clinical decision-making about antidepressant medication use in bipolar disorder. The next article, “Psychotropic Medications for Bipolar Disorder in Pregnancy,” by Drs. Andrea Favini and Sarah Homitsky summarizes risks and benefits of using medication to manage symptoms of bipolar disorder during the perinatal period. As they point out, compared to no treatment, treatment with medication during the perinatal period is associated with fewer symptoms and decreased risk of recurrence, yet many providers are unsure how to prescribe mood stabilizing medication during pregnancy. This article provides much needed information for providers to inform clinical decision-making during a phase of life where women are at increased risk for mood symptoms. The final article, “Beyond Pharmacotherapy for Bipolar Disorder: The Role of Adjunctive Psychological Treatments,” by Drs. Kathryn Fletcher and Greg Murray reminds readers that psychotherapy is an important component of illness management for bipolar disorder. Psychotherapy can help to improve symptoms and functioning and to reduce time to episode recurrence. They argue for the importance of taking a holistic approach to caring for people with bipolar disorder. They advocate for leveraging technology to incorporate self-management strategies into a comprehensive approach to care that targets improved quality of life.

These articles discuss salient topics related to the management of bipolar disorder. Readers will find them useful primers to advance their understanding of bipolar disorder and to provide practical suggestions for delivering even better care to those who need it.


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Holly A. Swartz, MD

Holly A. Swartz, MD, is a Professor of Psychiatry, University of Pittsburgh School of Medicine.

Address correspondence to Holly A. Swartz, MD, University of Pittsburgh School of Medicine, 3811 O'Hara Street, Pittsburgh, PA 15213; email:

Disclosure: Holly A. Swartz has received honoraria from Otsuka, grant support from Myriad Genetics, royalties from Wolters Kluwer, and royalties and an editorial stipend from American Psychiatric Association Publishing, Inc.


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