SAN FRANCISCO—Bipolar disorder (BD) is a “deadly disease” with high rates of comorbid conditions, and many challenges remain in diagnosing and treating it, Vladimir Maletic, MD, MS, said at Elevate by Psych Congress 2017.
Recognizing BD early on and effectively treating it may help diminish the comorbidities and mortality associated with the disease, said Dr. Maletic, Clinical Professor, Psychiatry and Behavioral Science, University of South Carolina School of Medicine, Greenville.
Dr. Maletic, also a member of the Psych Congress Steering Committee, outlined the variety of increased risks which people with BD face.
They are at least more than twice as likely as healthy individuals to suffer from migraine, asthma, chronic bronchitis, and chronic fatigue syndrome.
They are 2 to 3 times more likely than than healthy individuals to die from endocrine, cardiovascular, or cerebrovascular disturbances.
Vascular disease was identified in a large study as the leading cause of “excess deaths” in BD (deaths which could not be prognosticated in healthy individuals), surpassing suicide, which clinicians may more commonly associate with BD.
“As much as we ask about suicidal ideation, it behooves us to also at least have some rudimentary information about their cardiometabolic status,” Dr. Maletic said. “That is more likely to kill them.”
Suicide, however, is very common in bipolar depression and should always be asked about when treating patients with BD, he advised. Half of all patients with BD have attempted suicide, most often during a course of depression.
“Particularly toxic are mixed states,” Dr. Maletic said, calling depression with hypomania “energized misery.” “That is the time that they are at greatest risk,” he said.
Despite the known dangers, a lot of uncertainty remains about how to treat BD, and much treatment is off-label.
After diagnosis, antidepressants are the most commonly used unapproved monotherapy, being used twice as frequently as mood stabilizers, Dr. Maletic said. However, the literature on using antidepressants in BD is “all over the place,” he said. Some studies are neutral on the issue, some say the practice is dangerous, and some say they can be helpful.
Dr. Maletic offered some guidelines to follow when considering use of antidepressants in BD, from the International Society for Bipolar Disorders.
In Bipolar Disorder I, do not use antidepressants as monotherapy.
Antidepressants may be a good choice in patients with BD if they have been helped by them in the past, or had their symptoms worsen when going off one, but they must be combined with a mood stabilizer.
Avoid using antidepressants in patients with mixed mood episodes, rapid cycling, or moods that fluctuate up and down before leveling off.
There are “relatively few” drug choices shown effective in treating bipolar conditions, Dr. Maletic said. They include lamotrigine, quetiapine, olanzapine, olanzapine combined with fluoxetine, and lurasidone.
He urged attendees to also consider other types of interventions, such as working with family members, psychoeducation, helping patients improve diet and exercise habits, addressing substance use, managing comorbid conditions, minimizing nonadherence to medication, and encouraging participation in family or group therapy or support groups.
“It’s not all about pharmacology,” he said. “There are other meaningful interventions.”
“Updates to the diagnosis and management of bipolar depression: Have we been going about this all wrong?” Presented at Elevate by Psych Congress 2017; March 3, 2017; San Francisco, CA.