Posted by Phillipa on March 9, 2009, at 20:34:30
Interesting as atypical antipsychtics play large role. Phillipa
February 12, 2009 Bipolar disorder appears to increase the risk for premature death due to medical illness, including cardiovascular and cerebrovascular disease, endocrine disorders, and chronic obstructive pulmonary disease.
The first systematic review to examine mortality data in bipolar disorder shows that affected individuals have between a 1.5- and 2-fold increased risk for premature death due to these common medical conditions.
"It appears bipolar disorder is as big a risk factor for premature mortality as smoking. This is a major finding and drives home the message that as psychiatrists we should be regularly monitoring the physical status of our patients with chronic mental illness," principal investigator Wayne Katon, MD, from the University of Washington School of Medicine, in Seattle, said.
With first author Babak Roshanaei-Moghaddam, MD, the study is published in the February issue of Psychiatric Services.
Striking Findings
According to Dr. Katon, several studies have shown a link between major depression and an increased risk for early mortality due to general medical illnesses. Recent evidence from literature reviews in schizophrenia reveals similar results.
In the past, excess deaths associated with bipolar illness were attributed to unnatural causes, such as suicide, homicide, and unintentional injuries. However, a growing body of literature suggests this may account for only a portion of premature mortality in these individuals.
The investigators reviewed 17 studies involving more than 331,000 patients with bipolar disorder, affective psychosis, affective disorder requiring inpatient psychiatric care or treatment with lithium, or schizoaffective disorder.
Compared with age- and sex-matched control samples without mental illness from the general population, mortality ratios for death from natural causes and from specific general medical conditions such as heart disease, stroke, diabetes, and chronic obstructive pulmonary disease were significantly higher.
The investigators point out this finding was particularly striking in larger studies of more than 2500 patients with bipolar disorder.
Vicious Cycle
Although the mechanism is not entirely clear, Dr. Katon said research by his group investigating the link between major depression and conditions such as heart disease, osteoarthritis, and diabetes suggests there may be a bidirectional adverse interaction between chronic mental illness and medical illness.
Having a major mental illness such as bipolar disorder increases the likelihood of developing physical illness through a variety of factors, including poor diet, smoking, lack of exercise, substance abuse, social deprivation, and a lack of medical care, among others.
In addition, he said, the chronic stress inherent in having a major medical illness can affect the hypothalamic-pituitary-adrenal axis, increasing cortisol levels and leading to heightened activity of the sympathetic nervous system, possibly leading to earlier development of medical illness.
Once patients with a mental illness contract a medical illness, it is often a greater challenge for them to manage their condition. With diseases like diabetes, which requires a lot of self-care, poor management can lead to more complications, which in turn can feed back and exacerbate the mental-health condition.
"It really can turn into a vicious cycle," said Dr. Katon.
Role of Atypical Antipsychotics
Another potential contributing factor to physical illness and premature mortality in patients with bipolar disorder has been the introduction of second-generation, or atypical, antipsychotics and mood stabilizers, which are now in widespread use.
Although these agents have fewer adverse effects, including extrapyramidal symptoms, than their first-generation counterparts, they are associated with obesity and metabolic abnormalities that may increase the risk for morbidity and mortality resulting from diabetes and cardiovascular disease, the researchers note.
"So what we've seen in recent years is a beginning of the understanding in the field that mood stabilizers and atypical antipsychotics, although effective in treating mental illness, are bringing new problems to bear.
"This has really gotten people's attention and raised awareness in a way I've never seen before that, as psychiatrists, we need to pay closer attention to our patients' physical health. There's not much point in effectively treating them for their mental-health problems only to watch them die prematurely from their medical diseases," said Dr. Katon.
Attempts to reduce rates of premature mortality in mentally ill patients are under way and include increased training among psychiatry residents about common medical illnesses and the importance of addressing risk factors.
New Models of Care Needed
In addition, he said, new models of care that marry primary-care health services with community mental-health care are currently being developed and tested.
"Psychiatrists are now on the staff of a growing number of medical-specialty clinics, such as centers for diabetes, heart disease, and cancer, and at primary-care centers such as family-medicine practices," Dr. Katon said.
"Mental-health professionals are working side by side with providers who treat medical illnesses. New approaches to healthcare and wellness programs are being tested at a number of places to find effective models for preventing premature deaths associated with bipolar disorder and other mental illnesses," he added.
Dr. Katon discloses that he has received honoraria from Eli Lilly, Pfizer, Forest Laboratories, and Wyeth. He is also on an advisory board for Eli Lilly. Dr. Roshanaei-Moghaddam has disclosed no relevant financial relationships.
Psychiatr Serv. 2009;60:147-156.
Clinical Context
Bipolar spectrum disorders may promote early mortality through a number of mechanisms, as reviewed in the current study. The disease state itself is associated with higher serum cortisol levels and sympathetic activation, both of which may lead to the metabolic syndrome and atherosclerosis. Furthermore, most mood stabilizers are associated with weight gain, and second-generation antipsychotics can also promote diabetes. Finally, patients with severe mental health disorders often receive less attention for their chronic medical conditions, for a variety of reasons.The current study uses a comprehensive literature review to quantify the effect of bipolar spectrum disorders on the risk for death.
Study Highlights
Studies examining bipolar spectrum disorders and mortality data were collected from the MEDLINE database. Bipolar spectrum disorders included bipolar disorder, schizoaffective disorder, affective disorder requiring hospitalization or treatment with lithium, affective psychosis, or any combination of these disorders.
Only English-language studies with data on more than 100 patients were included in the review.
Of 44 studies identified in the initial query, 17 were included in the review. The studies included a total of 331,000 patients.
In one of the larger studies, bipolar and schizoaffective disorders were found to be independent predictors of earlier mortality. This effect was most pronounced in younger patients.
Another study demonstrated that affective psychosis was associated with a 35% increase in the risk for mortality.
There was evidence in 1 trial that the cardiovascular mortality rate was higher in patients with affective psychosis vs control subjects, but rates of revascularization procedures were lower for psychiatric patients.
1 study demonstrated that the risk for death attributable to bipolar disorder was highest in the first year after psychiatric hospitalization, and it declined thereafter.
Overall, bipolar spectrum disorders were associated with an increased risk for death, which varied between 35% and 100%.
Larger studies demonstrated that bipolar spectrum disorders increased the risks for mortality from multiple causes, including mortality related to cardiovascular, respiratory, cerebrovascular, and endocrine causes.
However, bipolar spectrum disorders did not generally increase the risk for cancer death, despite a higher number of cancer risk factors in these patients.
Cardiovascular causes accounted for the most excess deaths associated with bipolar spectrum disorders.
Pearls for Practice
Bipolar spectrum disorders may contribute to a higher risk for mortality because of higher levels of circulating cortisol, increased sympathetic activation, and negative metabolic effects of medications. In addition, patients with severe mental health disorders frequently receive worse care of medical conditions.
In the current study, bipolar spectrum disorders were associated with a higher risk for mortality, particularly death secondary to cardiovascular disease.
poster:Phillipa
thread:884665
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