Bipolar disorder and Medical Co-morbidities Peter J. Dorsen, M.D. LADC

by Peter J. Dorsen M.D., LADC

Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.

I had been taking lithium for an extended period of time for my bipolar II disorder.

What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!

The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”

My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.

Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.

When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!

Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?

Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”

McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”

In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.

Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.

This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.

Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.

It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.

As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.