Physical health of patients with bipolardisorder
Bipolar disorder patient has mood swings in which the mood alternates between extreme poles. You could go from being vey manic which is being excited to being depressed. This has affected around 3% of the population and has an alarming connection with suicide rates. The purpose of this article is reviewing the characteristics of Bipolar Disorder and approaches to minimize health risks to this mental disorder. They use research from a clinic and help you understand how the bipolar disorder is usually underrated because it is like major depressive episodes. The substance of this report is based on the November 2011 proceedings of a 1-day independent symposium and is augmented with the related literature. The symposium was organized to provide an outline of the historical history of bipolar disorder, the importance of tracking patients’ physical wellbeing on pharmacotherapy, the importance of psychoeducation as part of routine bipolar disorder care, and an example of a presently functioning bipolar clinic.
The workshop and the conference aimed to inform UK-based healthcare professionals (HCPs) about the benefits, obstacles and aspirations involved with developing a bipolar clinic and the services available in their own clinical practices.
As a psychiatric condition, bipolar disorder also involves regular pharmacotherapy and supervision, and the modification of health care services to the patient’s needs. In addition, patient awareness is required to avoid fast progression from manic to depressive symptoms as a result of drug non-adherence or inappropriate administration. Therefore, patients should be trained about how to cope with destabilizing influences that may contribute to symptoms of depressive or depression. Bipolar disorder care can control symptoms and episodes, but it is unlikely to result in complete recovery. The original treatment in fact poses an obstacle. Most patients seek treatment during depressive periods and are then misdiagnosed with unipolar MDD
or schizoaffective disorder. Concurrent comorbidities also add to the severity of the condition leading to misdiagnosis, undetected effects, drug coadministration and subsequent elevated risk of adverse events related to the care. Implementing interventions to identify bipolar disorder- specific signs, in addition to tools currently used to assess the mental state of a patient, may minimize the risk of misdiagnosis and increase clinical performance. Mental health and physical health are closely linked to risk factors such as weight gain, metabolic syndrome, smoking and diabetes which lead to cardiovascular disease, early death or potential suicide. Patients commonly use self-medication and drug abuse to alleviate symptoms of comorbidity or depression which put them at an increased health risk. Daily health tests are also necessary to ensure the patient gets the best treatment available. There is, however, a difference between the NICE recommendations and the amount and duration of safety tests that are carried out. Mental health and physical health are closely linked to risk factors such as weight gain, metabolic syndrome, smoking and diabetes which lead to cardiovascular disease, early death or potential suicide. Patients commonly use self-medication and drug abuse to alleviate symptoms of comorbidity or depression which put them at an increased health risk. Daily health tests are also necessary to ensure the patient gets the best treatment available. There is, however, a difference between the NICE recommendations and the amount and duration of safety tests that are carried out.
Bipolar disorder is a chronic, typically early‐onsetting mental disorder defined by a continuous risk of switch between remission and relapse. It is characterised by recurrent periods of depression and pathologically elevated mood consisting of increased energy and activity during which patients may experience sleep loss, overconfidence, impaired concentration and extreme talkativeness, and engage in irresponsible behaviour. As a result, it is often problematic to undertake usual activities and maintain interpersonal relationships [ 1] . An estimated 2.4% of the world’s population suffer from some form of bipolar disorder, with a lifetime prevalence of 0.6% for bipolar I disorder and 0.4% for bipolar II disorder, while 1.4% of the total population has a lifetime prevalence of subthreshold bipolar disorder [ 2] . Bipolar disorder should be considered in the context of approximately 450 million people worldwide who have a neuropsychiatric disorder [ 1] , which is associated overall with an increased risk of mortality. However, the number of deaths arising from mental disorders may be hugely underestimated, because a large number of suicides are classed as intentional injuries and not identified as suicides associated with a mental disorder [ 3] . The burden of mental disorders is likely to be underestimated as well, because of inadequate appreciation of the close connectedness between mental illness and other health conditions [ 3] . Unipolar and bipolar affective disorders, alcohol and substance use disorders, schizophrenia and dementia are among the most common neuropsychiatric conditions that contribute to an increased risk of comorbid physical diseases. It has been shown that depression predicts the onset and progression of physical and social disability, which in turn is an equally powerful prospective risk factor for depression in young people [ 4] .
Disease burden and mental instability are causal factors for a high rate of general mortality and suicide in psychiatric patients. The risk of suicide may increase during periods of rapid changes of the depressive state and would therefore occur mainly at the beginning and at the end of episodes, explaining why a large number of suicides occur during the first 6–12 months after discharge from hospital. Suicide rates are 13.5 times higher in men and 21.9 times higher in women with bipolar disorder, compared with the general population [ 5] .
Although the concept dates from antiquity, bipolar disorder was described in the nineteenth century as ‘circular madness’, indicating the recurrent symptoms of mania and depression with a prognosis being ‘desperate, terrible and incurable’ [ 6] . Despite the development of intensive antidepressant, antimanic and mood‐stabilising therapies, the long‐term outcome has not significantly improved over time. Full recovery without further episodes is rare; recurrence of episodes with incomplete remission is common, and the development of chronicity and suicide is still frequent. Historically, bipolar patients may remain hospitalised for approximately 20% of their lifetime with 50% of their episodes lasting 2–7 months [ 6] and a lifelong recurrence risk of 0.4 episodes per year [ 7] . Disease progression is individual, and the length of episodes and their cycling rhythm vary from patient to patient [ 6] . Episodes are defined as either depressive, manic or mixed, with a subset of characteristics to describe the mental state of a patient during and after a manic or depressive episode. Disease phases are determined by the level of response, remission and recovery a patient achieves. Deviations from an anticipated treatment outcome are usually described according to the nature of the current episode, and the following episode is described as relapse, recurrence or switch (Fig. [NaN] ) [ 8] , which can be assessed using established rating scales such as the Montgomery–Åsberg Depression Rating Scale or Young Mania Rating Scale. Diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) contain guidelines for the assessment and diagnosis of patients with mental illness. However, less formal diagnostic methods are widely used and contribute to a misdiagnosis of 45% of patients with bipolar disorders as
psychotic disorders, when presenting with manic symptoms [ 9] , or 31% as unipolar depressive, when presenting with depressive symptoms [ 10] .
Classification of bipolar disorders
There are two main classes of mood disorders: major depressive disorders (MDDs) and bipolar disorders. Each disorder is characterised by an individual set of symptoms, and a diagnosis takes into account the duration, nature and severity of the symptoms presented [ 11] .
Bipolar disorders are categorised into bipolar I and bipolar II disorder depending on patient history. Patients with bipolar I disorder have had at least one episode of mania; in some cases, previous episodes of depression, and mostly patients will have subsequent episodes that can be either manic or depressive. Patients meeting criteria for bipolar II disorder have a history of major depressive episodes (MDEs) and hypomanic episodes only [ 11] . Significant subthreshold mood symptomatology between episodes is detectable in both bipolar disorders. A diagnosis of bipolar disorder not otherwise specified (BP‐NOS) is substantiated by a patient with evidence of mood lability, hypomania and depressive symptoms, but failing to exhibit the same duration or severity criteria as bipolar II disorder.
Cyclothymic disorder may be diagnosed in patients who have never experienced a manic, mixed or depressive episode, but who experience numerous periods of depressive and hypomanic symptoms for at least 2 years, with no symptom‐free period greater than 2 months [ 11] .
The BRIDGE study
Although recurrent MDEs are characteristic of unipolar MDD, they are also an integral part of bipolar disorder. Because depressive episodes are generally more frequent and distressing than hypomanic episodes in bipolar disorder, patients tend to seek treatment for depression. As a result, patients with hypomanic episodes or subthreshold bipolar features remain unrecognised or misdiagnosed as unipolar MDD [ 10] . As a consequence of misdiagnosis and inadequate treatment, patients with bipolar disorder may be at increased risk of suicide, mood switching, cycling, mixed states, treatment resistance or non‐adherence to treatment. The BRIDGE (Bipolar Disorder: Improving Diagnosis, Guidance and Education) study addressed misdiagnoses of bipolar disorder by assessing the frequency of bipolar symptoms in patients with MDD using the DSM, fourth edition, text revision (DSM‐IV‐TR) criteria and the bipolarity specifier criteria. The diagnostic specifier for bipolar disorder identified substantially more patients with MDEs (47%) as having well‐ established bipolar features, based on the inclusion of indicators such as family history of bipolar disorder, comorbidity with substance abuse disorder or borderline personality disorder, compared with DSM‐IV‐TR criteria (16%) [ 10] . This study also identified a link between the use of antidepressants and the development of bipolar‐specific hypomania or manic episodes, which is not a diagnostic criterion in the DSM‐IV‐TR. The high percentage of patients misdiagnosed for bipolar disorder highlights that family history, illness course and clinical status, in addition to DSM‐IV‐ TR criteria, may provide useful information when assessing patients with MDD for bipolarity.
Bipolar II disorder – the EPIDEP study
The aim of the Epidemiologic Study in Bipolar Depression (EPIDEP) was to demonstrate that bipolar II disorder can be defined as a MDE associated with hypomania and/or cyclothymic disorder. Cyclothymic temperamental (CT) dysregulation emerged as a robust marker for bipolar II disorder and could present itself as a quantitative method for the diagnosis of this illness. Patients with bipolar II disorder display a more complex baseline of temperamental dysregulation (cyclothymic, depressive, hyperthymic and irritable) rather than a MDE, which could be considered a fundamental feature of bipolar II disorder. Persistent mood instability (cyclothymia) appears to be a major vulnerability factor for mood switching, which was shown to score high on the CT rating (CTR) scale [ 12] . Thus, mood switching can be considered a clinical marker for bipolar II disorder. In fact, the switch from unipolar to bipolar II disorder was best predicted by three temperamental factors: mood lability, energetic hyperactivity and daydreaming.
The EPIDEP study further demonstrated that using a patient‐ and clinician‐rated CTR scale in conjunction with structured interviews, inexperienced psychiatrists managed to correctly diagnose bipolarity in all of its varieties: especially psychotic, mixed manic and bipolar II disorder forms. The highest score on the CTR scale was observed in patients with bipolar II disorder; therefore, assessing CTR can be a major diagnostic clue for recognising bipolar II disorder in patients seeking help for depression [ 12] .
Quality of life of patients with bipolar disorder
Patients with bipolar disorder encounter many difficulties in leading a normal lifestyle even with the support of family, friends and carers and therefore tend to have a low quality of life (QoL), which is powerfully influenced by two factors: the nature of mental illness itself and treatment‐related comorbidity. Although a large number of patients do not meet the full syndromal criteria for manic‐depressive illness, they may display moody, irritable, erratic and volatile behaviour, which contributes to a life of isolation and misunderstanding. Many of those patients may have received a prior diagnosis of passive–aggressive, histrionic, antisocial or borderline personality disorder . Features of social disability that may be displayed by patients with bipolar disorder include problems in developing and sustaining friendships, and difficulties in maintaining intimate relationships with a partner. Furthermore, the inability to manage money, housework and coping with an emergency [ 13] impedes a normal lifestyle.
Possibly as a consequence of poor QoL, ‘self‐medication’ with alcohol, drugs and smoking is a regular occurrence in this patient population [ 14] , which increases the risk of developing comorbid conditions that result in an even poorer QoL. This combined with a sedentary lifestyle [ 15] and treatment‐related comorbidities such as weight gain, and changes in blood glucose and lipid levels [ 16] , are key factors in the development of long‐term conditions such as cardiovascular disease, obesity, metabolic syndrome and diabetes. Serious health concerns, additional polypharmacy and impairment of the patient’s lifestyle may in turn lead to more self‐medication and depression. Patients with bipolar II disorder spend long periods of time depressed, with the ratio of depression to mania/hypomania being 37 : 1 and 3 : 1
for bipolar II and bipolar I disorder, respectively [ 17] . Disease burden and mental instability are contributing factors to a high rate of suicides in mentally ill patients. Therefore, early pharmacotherapy and psychoeducational programmes, as well as cognitive behaviour therapy or family‐focused therapy, may improve patient QoL. Improving bipolar disorder symptoms with pharmacotherapy and psychoeducation helps the patient re‐integrate into society and reduces the risk of developing comorbidities, thus allowing them to lead a normal lifestyle.
Physical wellbeing in bipolar disease
Patients with bipolar disorder are prone to exhibit key risk factors for cardiovascular disease, such as obesity, smoking, hypertension, hyperglycaemia, dyslipidemia and type 2 diabetes. Furthermore, treatment options for bipolar disorder, mainly antipsychotics, have been linked to increased risk of changes in metabolic parameters, which could further increase the overall risk of developing comorbidity [ 16] . The prevalence of comorbid physical health conditions in patients with bipolar disorder is twice that of the general population. Ischaemic heart disease, stroke, hypertension and diabetes occur at rates of 5.1%, 1.5%, 14.7% and 4.1%, respectively, in patients with bipolar disorder [ 18] . The early onset of bipolar disorder has been correlated with an earlier onset of these comorbid conditions, compared with the general population [ 19] .
Aims of the study
This article reviews the characteristics of bipolar disorder and approaches to minimise physical health risks, as well as treatment options, and how they can influence patient QoL.
Material and methods
The content of this article is based on the proceedings of a 1‐day standalone symposium in November 2011 and supplemented with the relevant literature. The symposium was designed to give an overview of the natural history of bipolar disorder, the importance of monitoring the physical health of patients on pharmacotherapy, the importance of psychoeducation as part of standard treatment for bipolar disorder and an example of a bipolar clinic currently in operation. The objective of the workshop and the meeting was to educate UK‐based healthcare professionals (HCPs) about the opportunities, challenges and expectations associated with setting up a bipolar clinic with the resources available in their own clinical practices.
Minimising health‐related risk factors Cardiovascular disease
Cardiovascular disease is the largest contributor to mortality in severe mental illness (SMI), a term used to summarise schizophrenia and bipolar disorder for epidemiological general health studies. Diabetes, metabolic syndrome and smoking promote cardiovascular disease progression and are the most important target comorbidities to improve in overall patient health. Growing evidence suggests that patients with mental illness may receive low‐intensity care for a number of medical conditions [ 20] due to time constraints that limit a mental‐health specialist’s capacity to provide preventative services and a lack of familiarity with medical risk factors such as obesity and cardiovascular disease [ 15] .
Reducing the risk of obesity in patients with bipolar disorder may be complicated by patients reporting poor nutrition, medical comorbidities and a sedentary lifestyle [ 15] . In fact, 21–63% of patients with bipolar disorder exhibit metabolic syndrome [ 21] , a condition that leads to diabetes, and it is 2–3 times more prevalent in patients with SMI [ 22] compared with the general population. The use of psychotropic medication may be a major contributor to metabolic syndrome, by stimulating appetite receptors in the brain thus promoting abdominal obesity [ 22] . In addition, patients
with bipolar disorder are more likely to report suboptimal exercise habits than those with schizophrenia or no SMI [ 15] , and a significant exercise intolerance as a consequence of smoking habits, weight and medication [ 23] . A sedentary lifestyle accompanied by weight gain and medical comorbidities may also increase the vulnerability of the patient to further depressive recurrences. Therefore, treatment interventions aimed at improving nutrition and exercise habits should be tailored to the unique barriers faced by patients with bipolar disorder [ 15] and should be based on incremental lifestyle changes rather than drastic changes in patient behaviour. Educational campaigns such as changes in food options, motivational interviewing and regular health screening are necessary to promote a healthy lifestyle [ 24] . The National Institute for Health and Clinical Excellence (NICE) recommends that HCPs should offer advice on diet, physical activity and weight loss, and monitor blood pressure and blood glucose to support patients to control their weight [ 25] and alternatively to refer patients to a dietician or other specialised services [ 26] .
Self‐medication with alcohol, illicit drugs or misuse of prescription medication to relieve affective symptoms is common among individuals (24%) with mood disorders, and rates of self‐medication are higher for alcohol than for drugs . However, the highest rates of self‐medication occur in patients with bipolar I disorder where 38–41%, tend to use alcohol or drugs to relieve symptoms, mainly during the depressive phase. In contrast, 32% of patients with bipolar II disorder in the depressive phase and 8% in the hypomanic phase self‐medicate. Consistent with these findings is the higher prevalence for alcoholism in patients with bipolar I disorder (41%), compared with bipolar II disorder (25%). Frequently cited reasons for substance abuse in these patients include improving mood, alleviating tension, achieving or maintaining euphoria, and increasing energy [ 14] . Despite men being more than twice as likely to use substances to relieve distressing mood symptoms, which lead to lifetime alcoholism, women with bipolar disorder are particularly vulnerable to alcoholism, compared with the general female population [ 27] . Patients engaging in self‐ medication are more likely to be divorced or widowed and of young age. Although these individuals may engage in substance abuse with the intention of improving their mood, self‐medication is a strategy associated with significant mental illness comorbidity. Bipolar disorder is twice as likely to be accompanied by alternative psychiatric disorders such as eating, anxiety or substance abuse disorders than to exist by itself . Therefore, first evaluations of patients with bipolar disorder need to be comprehensive to anticipate possible future tendencies for substance abuse and counteract those with appropriate education.
Smoking is another way of self‐medicating; although it is not recognised as such. Approximately 75–85% of patients with SMI are smokers, and many have increased morbidity and mortality because of tobacco‐ related medical diseases. Smokers with SMI experience increased psychiatric symptoms, hospitalisations and the need for higher medication doses, compared with non‐smokers with SMI. Furthermore, heavy smokers in this patient population have increased positive symptoms (hallucinations and delusions) and negative symptoms (anhedonia, alogia, low motivation, poor social skills), compared with non‐smokers and light smokers [ 29] , as well as an increased risk of cardiovascular disorders . It has been reported that in a third of patients with bipolar disorder who regularly smoke, the natural bipolar cycle may be aggravated through a greater magnitude of episodic symptoms, more frequent episodes of both affective poles and rapid cycling. Destabilisation of the bipolar cycle may also affect individual episodic lengths and inter‐episodic mood stability. Smoking seems to be associated with poor treatment outcomes in bipolar mania and additionally increases the rate of treatment discontinuation. Consequently, smoking should not be regarded as a prevalent lifestyle habit among patients with mental illness, but as a comorbid condition requiring active intervention. Strategies to reduce smoking and smoking‐related risks could include introducing adequate smoking cessation programmes supported by mental‐health clinicians trained in cessation techniques and targeted educational promotions to reduce smoking initiation
Monitoring physical health in patients with bipolar disorder
Regular reviews of physical health are a major component in preventing or correctly managing comorbidities associated with bipolar disorder. In particular, obesity and cardiovascular risk factors need regular screening. NICE [ 26] recommends that primary‐care providers should test the following annually: lipid levels, including cholesterol in all patients above 40 years; plasma glucose levels; weight; blood pressure; smoking status; and alcohol use. NICE guidelines recommend measuring weight, height, plasma glucose and lipids in all patients initiating long‐term pharmacological management of bipolar disorder, and an electrocardiogram arranged for patients with a risk of cardiovascular disease. Guidelines further recommend that patients taking antipsychotics should have their weight checked every 3 months for the first year of treatment (more so if weight is gained rapidly) and plasma glucose and lipids 3 months after initial treatment (more often at elevated levels). Despite these recommendations, the majority of patients do not receive the regular physical health monitoring they require in addition to pharmacotherapy. Although evidence shows that 87% of patients with SMI receive one or more screening tests for cardiovascular disease, the individual rates of screening are much lower (weight check, 56%; glucose blood test, 36%; cholesterol blood test, 29%) [ 32] , and an annual physical review is only performed in 64% of patients receiving mood stabilisers [ 33] . Furthermore, only a small proportion of patients received health promotion advice (healthy eating, 16%; gym referral, 20%; weight reduction, 15%; smoking cessation, 38%) [ 32] .
As a chronic illness, bipolar disorder often requires continuous pharmacotherapy and monitoring and the adaption of healthcare resources to the needs of the patient. Moreover, patient education is necessary to prevent rapid cycling from manic to depressive episodes as a result of non‐adherence or incorrect administration of medication. Thus, patients should be educated on how to deal with destabilising factors that could lead to manic or depressive episodes.
The treatment for bipolar disorder can manage symptoms and episodes, but is unlikely to lead to full recovery [ 6] . The initial diagnosis is a challenge in itself. Many patients seek help during episodes of depression and are subsequently misdiagnosed with unipolar MDD or schizoaffective disorder. Concurrent comorbidities often contribute to disease complexity leading to misdiagnosis, undetected symptoms, coadminstration of medication and associated increased risks of treatment‐related adverse events. Introducing measures that recognise symptoms specific to bipolar disorder, in addition to methods already available for determining a patient’s mental state, could reduce the risk of misdiagnosis and improve treatment outcome.
Bipolar disorder is a common and severe mental disorder often under‐recognised by psychiatrists in patients with MDEs. Patients with bipolar disorder are often dependent on family and carers to lead a normal lifestyle and have difficulties maintaining relationships with friends and partners.
Mental health and physical health are closely linked, with risk factors such as weight gain, metabolic syndrome, smoking and diabetes contributing to cardiovascular disease, early death or potential suicide. Self‐medication and substance abuse are often used by patients to relieve symptoms of comorbidity or depression placing them at an increased health risk. Therefore, regular health checks are required to ensure that the patient receives the best possible care. However, there is a discrepancy between NICE guidelines and the number and frequency of health checks being performed.
Early pharmacotherapeutic and psychoeducational interventions are essential to improve treatment outcomes, as well as improving the patient’s understanding of how to minimise health risks. Atypical antipsychotics are an effective and preferred treatment for bipolar disorder, but may negatively impact on physical health and, by this, also contribute to a low QoL for patients with bipolar disorder. Bipolar clinics, as a way of delivering psychoeducation, may not only promote patient understanding, but ultimately improve quality of care.
The meeting on which this supplement is based was supported by Bristol‐Myers Squibb, Uxbridge, UK. Editorial support for the preparation of this manuscript was provided by Ogilvy Healthworld Medical Education, London, UK; funding was provided by Bristol‐Myers Squibb.
Young, A. H., & Grunze, H. (2013). Physical health of patients with bipolar disorder. Acta Psychiatrica
Scandinavica, 127, 3–10. https://doi-org.ctcproxy.mnpals.net/10.1111/acps.12117
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Using proper APA formatting, cite the peer-reviewed article you selected that pertains to your practice area and is of particular interest to you and identify the database that you used to search for the article. Explain any difficulties you experienced while searching for this article. Would this database be useful to your colleagues? Explain why or why not. Would you recommend this database? Explain why or why not.
Heres the peer review article i selected: Physical and mental health status of former smokers and non‐smokers patients with bipolar disorder.
Nobile, B., Godin, O., Gard, S., Samalin, L., Brousse, G., Loftus, J., Aubin, V., Belzeaux, R., Dubertret, C., Le Strat, Y., Mazer, N., Prémorel, A., Roux, P., Polosan, M., Schwintzer, T., Llorca, P., Biseul, I., Etain, B., Moirand, R., … Icick, R. (2023). Physical and mental health status of former smokers and non‐smokers patients with bipolar disorder. Acta Psychiatrica Scandinavica. https://doi.org/10.1111/acps.13535
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