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.
- Merikangas KR, Jin R, He J-P, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241–251. https://doi.org/10.1001/archgenpsychiatry.2011.12 PMID: doi:10.1001/archgenpsychiatry.2011.12 [CrossRef]21383262
- Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530–537. https://doi.org/10.1001/archpsyc.59.6.530 PMID: doi:10.1001/archpsyc.59.6.530 [CrossRef]12044195
- Judd LL, Akiskal HS, Schettler PJ, et al. Psychosocial disability in the course of bipolar I and II disorders: a prospective, comparative, longitudinal study. Arch Gen Psychiatry. 2005;62(12):1322–1330. https://doi.org/10.1001/archpsyc.62.12.1322 PMID: doi:10.1001/archpsyc.62.12.1322 [CrossRef]16330720
- Maina G, Albert U, Bellodi L, et al. Health-related quality of life in euthymic bipolar disorder patients: differences between bipolar I and II subtypes. J Clin Psychiatry. 2007;68(2):207–212. https://doi.org/10.4088/JCP.v68n0205 PMID: doi:10.4088/JCP.v68n0205 [CrossRef]17335318
- Michalak EE, Yatham LN, Lam RW. Quality of life in bipolar disorder: a review of the literature. Health Qual Life Outcomes. 2005;3(1):72. https://doi.org/10.1186/1477-7525-3-72PMID: doi:10.1186/1477-7525-3-72 [CrossRef]16288650
- Bonnín CM, Sánchez-Moreno J, Martínez-Arán A, et al. Subthreshold symptoms in bipolar disorder: impact on neurocognition, quality of life and disability. J Affect Disord. 2012;136(3):650–659. https://doi.org/10.1016/j.jad.2011.10.012 PMID: doi:10.1016/j.jad.2011.10.012 [CrossRef]
- Novick DM, Swartz HA, Frank E. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the evidence. Bipolar Disord. 2010;12(1):1–9. https://doi.org/10.1111/j.1399-5618.2009.00786.x PMID: doi:10.1111/j.1399-5618.2009.00786.x [CrossRef]20148862
- Schaffer A, Isometsä ET, Tondo L, et al. International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder. Bipolar Disord. 2015;17(1):1–16. https://doi.org/10.1111/bdi.12271 PMID: doi:10.1111/bdi.12271 [CrossRef]
- Weiner M, Warren L, Fiedorowicz JG. Cardiovascular morbidity and mortality in bipolar disorder. Ann Clin Psychiatry. 2011;23(1):40–47. PMID:21318195
- Hayes JF, Marston L, Walters K, King MB, Osborn DPJ. Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014. Br J Psychiatry. 2017;211(3):175–181. https://doi.org/10.1192/bjp.bp.117.202606 PMID: doi:10.1192/bjp.bp.117.202606 [CrossRef]28684403
- Nierenberg AA, Sylvia LG, Leon AC, et al. Bipolar CHOICE Study Group. Clinical and Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE): a pragmatic trial of complex treatment for a complex disorder. Clin Trials. 2014;11(1):114–127. https://doi.org/10.1177/1740774513512184 PMID: doi:10.1177/1740774513512184 [CrossRef]
- Swartz HA, Rucci P, Thase ME, et al. Psychotherapy alone and combined with medication as treatments for bipolar II depression: a randomized controlled trial. J Clin Psychiatry. 2018;79(2):16m11027. https://doi.org/10.4088/JCP.16m11027 PMID: doi:10.4088/JCP.16m11027 [CrossRef]
- Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97–170. https://doi.org/10.1111/bdi.12609 PMID: doi:10.1111/bdi.12609 [CrossRef]29536616
- Wisner KL, Sit D, O'Shea K, et al. Bipolar disorder and psychotropic medication: impact on pregnancy and neonatal outcomes. J Affect Disord. 2019;243:220–225. https://doi.org/10.1016/j.jad.2018.09.045 PMID: doi:10.1016/j.jad.2018.09.045 [CrossRef]
- Hirschfeld RM. Bipolar depression: the real challenge. Eur Neuropsychopharmacol. 2004;14(suppl 2):S83–S88. https://doi.org/10.1016/j.euroneuro.2004.03.001 PMID: doi:10.1016/j.euroneuro.2004.03.001 [CrossRef]15142612