The Bad News Plus The Good News - A Guest Editor

It's been a long time since I posted at Madam Bipolar but I am still determined to keep this as a place where people can go to for mental illness information.

That's why I am pleased to announce that Candida Abrahamson is going to guest edit this blog for a stint. I am sure many of you may know her work, which sets a standard on the internet for excellence in healthcare writing.

This period will also showcase the work of Rhona Finkle, who has written this week's piece on bipolar disorder and co-morbidity.

Here is the post and it is my pleasure to introduce them to you:

Medical Comorbidity in Bipolar Disorder: Just the (Unpleasant) Facts

By: RHONA FINKEL

"Bipolar Disorder ranks as the sixth leading cause of disability in the world, with an economic burden to . . .the US alone . . .[of] $7 billion in direct medical costs and $38 billion (1991 values) in indirect costs. . . .[P]atients with BD sustain health-care utilization costs that are as much as four times greater than costs for nonbipolar patients and a considerable part of these costs is driven by medical illness." ~ Soreca et al, 2009

Bipolar disorder (BD) is an illness with some scary statistics.

Its suicide rate is higher than that of any other mental illness, clocking in at 20%.

Over 50% of those with BD have substance abuse issues.

According to the National Institute of Mental Health, it results in a 9.2-year reduction in life span.

In short, it's a not an easy disorder with which to contend.

To make the situation vastly more challenging, it seems that people with BD have more medical comorbidities than those with other mental illnesses, complicating treatment, and contributing to shortening of lives.

Although the co-occurrence of physical illness in persons with schizophrenia has been addressed in multiple studies (see MC Ryan 2002, J Baldwin 1979, DR Folsom 2002, and Sernyak 2003--and get back to me if that doesn’t do it for you), before about 2005, medical co-morbidity in BD patients had received scant attention, even though the disorder itself is significantly more common than schizophrenia.

Finally a 2005 study, "Medical Comorbidity in a Bipolar Outpatient Clinical Population," looked at 1379 patients with bipolar disorder treated from 2001-2002 in outpatient clinics, perhaps assuming that an outpatient population might be a healthier one.

Nevertheless, it found systemic disease too common for comfort, with high percentages of endocrine and metabolic diseases, and diseases of the circulatory system, as well as of the nervous system and sense organs.

Cardiovascular diseases/hypertension, COPD/asthma, and diabetes were all common specific illnesses, and ones which correlate regularly across studies with BD.

In fact, cardiovascular and cerebrovascular diseases occur in BD at twice the rate of the general population (Soreca et a 2009).

Interestingly, the study left some illnesses un-addressed that are well-known to be associated with BD. For example, an estimated 25-27% of BD people suffer from migraines (e.g. T Mahmood et al 1999). Additionally, thyroid disease (see Cole et al 2002) is more frequently diagnosed in BD patients as doctors become increasingly knowledgeable about the inter-connections.

The 2005 paper was a toe in the water. Soon others jumped in head first.

Two 2006 papers only made the situation appear more drastic.

"Medical Comorbidity in Women and Men With Bipolar Disorders: A Population-Based Controlled Study" studied a sample of administrative claims from 1996 to 2001 from Wellmark Blue Cross Blue Shield, which covered 3557 bipolar I patients. The authors determined that people with BD had increased likelihoods of contracting conditions spanning every organ system.

And results from the 2006 "Medical Comorbidity in Bipolar Disorder: Implications for Functional Outcomes and Health Service Utilization" (McIntyre et al) further clarified the depth of the problem.

In the first "cross-national population-based investigation exploring the prevalence and functional implications of comorbid general medical disorders in bipolar disorder,” the authors found that

Rates of chronic fatigue syndrome, migraine, asthma, chronic bronchitis, multiple chemical sensitivities, hypertension, and gastric ulcer were significantly higher in the bipolar disorder group [in comparison to controls].

Adding to the tragedy of the situation, the bipolar illness itself became more recalcitrant and difficult to treat as the number and severity of medical illnesses increased:

Chronic medical disorders were associated with a more severe course of bipolar disorder, increased household and work maladjustment, receipt of disability payments, reduced employment, and more frequent medical service utilization.

Once the groundwork had been laid by these early studies, observers were quick to realize that physical illness all too often went hand in hand with BD, and study followed study confirming the correlation. The most surprising aspect is that it took so long for published work to validate what so many people with BD intuitively know.

In an unusual 2009 analysis David Kemp (Case Western Reserve University, Cleveland, Ohio) and colleagues looked at 98 adult outpatients with rapid-cycling bipolar I or II disorder and co-occurring substance abuse disorders. Because substance abuse is so common among this population, throwing it into the mix in assessing physical conditions made good sense.

The results were pretty shocking.

Every single patient enrolled in the study had at least one medical illness.

And, to strain credulity more, on average the subjects had 4.9 different medical conditions.

The disheartening stats just kept on coming:

·     52% had illnesses crossing four or more different organ systems,

·     24% had uncontrollable medical illnesses, and

·     the mean overall total Cumulative Illness Rating Scale score was 5.56 (4 is considered high).

·     38% were overweight and 29% obese.

AND--insult to injury--the number of medical illnesses increased with age, so an older person struggling with BD had both more mood stability behind her—and now increased physical challenges making the fight for stability all that much more difficult.

Number of Medical Comorbidities Stratified by Age Among Patients with Rapid-Cycling Bipolar I or II Disorder and Co-Occurring Substance Use Disorders (Kemp et al 2009)

Just to bring us to the present, the most recent relevant data comes again from David Kemp, who was back in action, this time studying 264 patients with bipolar I or II disorder in the Lithium Treatment Moderate Dose Use Study.

Presented at the 52nd Annual Meeting of the New Clinical Drug Evaluation Unit in Phoenix  this pasts May 29-June 1, 2012, these were inpatients, which might have added a level of complication--but this time rapid cycling and substance abuse were not requirements, so the degree of comorbid illness should be--and was, to some extent--lower.

But not low enough.

Guesses on the percentage of those patients who had significant medical comorbidity? Anybody?

A staggering 53%.

That's right. More than half of BD patients had a physical illness.

The most commonly affected systems for the inpatient population, slightly different from the outpatients, were the:

·     musculoskeletal/integumentary (33%),

·     the respiratory (27%), and

·     the endocrinologic/metabolic (25%) systems.

The most common individual conditions were:

·     migraine (25%) [no surprise, that statistic regularly recurs in research],

·     history of head trauma with loss of consciousness (19%), and

·     hypertension (16%).

And, once again, a greater medical illness profile correlated with a larger number of mood episodes.

Kemp et al note of their findings:

In this generalizable sample of patients with bipolar I and II disorder, the burden of comorbid medical illnesses is high and appears to influence course of illness and psychotropic medication patterns. (see MedWireNews)

It is a terrible irony. When all resources are needed, emotional, physical, mental, material, to fight against an illness, the illness is at the same time siphoning those resources off.

But if there is the will to fight, there is hope. Painter Edvard Munch, perhaps not a paragon of mental health, but certainly someone who would have been a seriously rich man had he only but lived long enough, said it best:

Without fear and illness, I could never have accomplished all I have.

So that is our mission: to fight on despite fear, despite mood dysregulation, despite multiple illnesses, to show how greatness can be achieved, just by overcoming.

REFERENCES

Beyer J et al. Medical comorbidity in a bipolar outpatient clinical population. Neuropsychopharmacology 2005; 30(2):401-4.

Carney CP, Jones LE. Medical Comorbidity in Women and Men With Bipolar Disorders: A Population-Based Controlled Study.Psychosomatic Medicine 2006; 68(5):684-691.

Cowen M. High medical illness rates in bipolar disorder. 28 June 2012.

Kemp DE, et al. Medical and Substance Use Comorbidity in Bipolar Disorder. Journal of Affective Disordors 2009; 116(1-2):64–69.

Kemp DE, et al. Medical comorbidity in bipolar disorder: relationship between illnesses of the endocrine/metabolic system and treatment outcome. Bipolar Disorder 2010; 12(4):404–413.

McIntyre RS, et al. Medical Comorbidity in Bipolar Disorder: Implications for Functional Outcomes and Health Service Utilization. Psychiatric Services 2006; 57(8).

Soreca I, Frank E, Kupfer DJ. The phenomenology of bipolar disorder: what drives the high rate of medical burden and determines long-term prognosis? Depression and Anxiety 2009; 26(1):73–82.

About Rhona and Candida:

Dr. Candida Abrahamson has been coaching and mediating since graduating with a Ph.D. from Northwestern University in 1984. She helps adults and adolescents through the particular struggles of our time: tension between couples, parenting frustration, blending new families, separation and divorce, (un)employment, cancer, and loss. With reason and moderation she assists people in shifting from fear and hopelessness to problem-solving and respect. When relationships come to an impasse, she uses mediation techniques to try to ensure that each party will have his/her needs heard and accounted for in a dignified way. In addition to talking, listening, and reframing, she utilizes the tools of metaphor, active teaching, role-playing, visualization, and occasionally hypnotherapy.

Her website is  http://candidaabrahamsonphd.com/,  and you can find more posts like this one on her blog at http://candidaabrahamson.wordpress.com.

Co-author Rhona Finkel is a Princeton University graduate who now researches and writes on science and mental health issues, covering topics as wide-ranging as retractions in scientific literature, mood disorders, technology and health, the plight of the mentally ill, psychiatric medications, and sociology research. Additionally she does PR for individuals and businesses, beefing up websites, establishing Internet presences, creating social platforms for owners, and then training them in how to use social media to their benefit. She is privileged to be an author on Candida Abrahamson’s Blog.