More on Mania and Mortality

by Peter J. Dorsen M.D., LADC

Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.

Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.

The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein (the “good” cholesterol).

Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.

There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users (N Engl J Med 2009, 360:225-235).

Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.

These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.

In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”