Curr Psychiatry Rep (2014) 16:499 DOI 10.1007/s11920-014-0499-z
BIPOLAR DISORDERS (W CORYELL, SECTION EDITOR)
Excess Mortality in Bipolar Disorders Christopher Miller & Mark S. Bauer
Published online: 7 September 2014 # Springer Science+Business Media New York (outside the USA) 2014
Abstract Bipolar disorder is associated with high mortality, and people with this disorder on average may die 10–20 years earlier than the general population. This excess and premature mortality continues to occur despite a large and expanding selection of treatment options dating back to lithium and now including anticonvulsants, antipsychotics, and evidence-based psychotherapies. This review summarizes recent findings on mortality in bipolar disorder, with an emphasis on the role of suicide (accounting for about 15 % of deaths in this population) and cardiovascular disease (accounting for about 35– 40 % of deaths). Recent care models and treatments incorporating active outreach, integrated mental and physical health care, and an emphasis on patient self-management have shown promise in reducing excess mortality in this population. Keywords Bipolar . Mortality . Suicide . Cardiovascular
Introduction Bipolar disorder is associated with high morbidity, mortality, and risk of suicide [1–5]. People with this disorder on average may die 10–20 years earlier than the general population [6]. There is at least preliminary evidence that excess mortality in bipolar disorder has also been growing more pronounced in
recent years [7]. These negative outcomes continue to occur despite a large and expanding selection of treatment options dating back to lithium [8] and now including anticonvulsants [9, 10], antipsychotics [11–14], and evidence-based psychotherapies [15–19]. This review aims to summarize research over the prior three years on excess mortality in bipolar disorder.
Methods An initial literature search was conducted using PubMed, with search terms of “bipolar” and “mortality” identifying a broad pool of articles. Titles of such articles published since 2011 were scanned to yield articles for inclusion. Secondary searches investigating particular aspects of bipolar mortality (e.g., bipolar+ suicid$, bipolar+cardio$, and related searches on the PubMed and Google Scholar platforms) yielded additional articles, and the reference lists of selected articles and reviews were examined in a snowball sampling approach. While the focus of the review was on empirical studies published since 2011, some older articles were included to provide context. The authors also emailed other experts in the field directly to inquire about recent findings that may still be unpublished or in press.
Results This article is part of the Topical Collection on Bipolar Disorders C. Miller (*) : M. S. Bauer Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA e-mail: [email protected] M. S. Bauer e-mail: [email protected] C. Miller : M. S. Bauer Department of Psychiatry, Harvard Medical School, Boston, MA, USA
Sampling Frame In total, the search method described above yielded 22 empirical studies since 2011 that were relevant for inclusion. Additional supporting articles (including older studies, metaanalyses, and other reviews) provided context. Two major themes emerged as being particularly critical to excess mortality in bipolar disorder: suicide and cardiovascular disease (CVD). Other factors (e.g., comorbid substance abuse,
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accidents) have also been implicated. These issues are covered in separate sections below. Recent Research on Suicide in Bipolar Disorder A large body of research dating back decades has demonstrated that people with bipolar disorder may be 15–30 times more likely to complete suicide than the general population [20–22]. Two caveats are worth considering, however. First, many previous studies drew their samples from inpatient populations, and so the suicide risk among the entire bipolar population (including inpatients, outpatients, and those who never seek treatment) may in fact be lower. On the other hand, people with bipolar depression may have their suicides attributed to unipolar major depression, in which case suicide risk in bipolar disorder may in fact be higher than previous estimates. Given this overall elevated risk, recent research has explored several facets of bipolar suicide risk. Suicide Risk Factors not Unique to Bipolar Disorder First, while it would be beyond the scope of this review to document all recent research on suicide, most risk factors for suicide in the general population also serve as risk factors for suicide among people with bipolar disorder. For example, one recent report from the Systematic Treatment Enhancement for Bipolar Disorder study (STEP-BD) investigated suicide events among 3,083 people diagnosed with bipolar disorder [23]. These suicide events included 140 attempts, of which eight were fatal. Consistent with the non-bipolar literature, the strongest predictor of a suicide event was a past history of suicide attempt (hazard ratio=2.60, p
BIPOLAR DISORDERS (W CORYELL, SECTION EDITOR)
Excess Mortality in Bipolar Disorders Christopher Miller & Mark S. Bauer
Published online: 7 September 2014 # Springer Science+Business Media New York (outside the USA) 2014
Abstract Bipolar disorder is associated with high mortality, and people with this disorder on average may die 10–20 years earlier than the general population. This excess and premature mortality continues to occur despite a large and expanding selection of treatment options dating back to lithium and now including anticonvulsants, antipsychotics, and evidence-based psychotherapies. This review summarizes recent findings on mortality in bipolar disorder, with an emphasis on the role of suicide (accounting for about 15 % of deaths in this population) and cardiovascular disease (accounting for about 35– 40 % of deaths). Recent care models and treatments incorporating active outreach, integrated mental and physical health care, and an emphasis on patient self-management have shown promise in reducing excess mortality in this population. Keywords Bipolar . Mortality . Suicide . Cardiovascular
Introduction Bipolar disorder is associated with high morbidity, mortality, and risk of suicide [1–5]. People with this disorder on average may die 10–20 years earlier than the general population [6]. There is at least preliminary evidence that excess mortality in bipolar disorder has also been growing more pronounced in
recent years [7]. These negative outcomes continue to occur despite a large and expanding selection of treatment options dating back to lithium [8] and now including anticonvulsants [9, 10], antipsychotics [11–14], and evidence-based psychotherapies [15–19]. This review aims to summarize research over the prior three years on excess mortality in bipolar disorder.
Methods An initial literature search was conducted using PubMed, with search terms of “bipolar” and “mortality” identifying a broad pool of articles. Titles of such articles published since 2011 were scanned to yield articles for inclusion. Secondary searches investigating particular aspects of bipolar mortality (e.g., bipolar+ suicid$, bipolar+cardio$, and related searches on the PubMed and Google Scholar platforms) yielded additional articles, and the reference lists of selected articles and reviews were examined in a snowball sampling approach. While the focus of the review was on empirical studies published since 2011, some older articles were included to provide context. The authors also emailed other experts in the field directly to inquire about recent findings that may still be unpublished or in press.
Results This article is part of the Topical Collection on Bipolar Disorders C. Miller (*) : M. S. Bauer Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA e-mail: [email protected] M. S. Bauer e-mail: [email protected] C. Miller : M. S. Bauer Department of Psychiatry, Harvard Medical School, Boston, MA, USA
Sampling Frame In total, the search method described above yielded 22 empirical studies since 2011 that were relevant for inclusion. Additional supporting articles (including older studies, metaanalyses, and other reviews) provided context. Two major themes emerged as being particularly critical to excess mortality in bipolar disorder: suicide and cardiovascular disease (CVD). Other factors (e.g., comorbid substance abuse,
499, Page 2 of 7
accidents) have also been implicated. These issues are covered in separate sections below. Recent Research on Suicide in Bipolar Disorder A large body of research dating back decades has demonstrated that people with bipolar disorder may be 15–30 times more likely to complete suicide than the general population [20–22]. Two caveats are worth considering, however. First, many previous studies drew their samples from inpatient populations, and so the suicide risk among the entire bipolar population (including inpatients, outpatients, and those who never seek treatment) may in fact be lower. On the other hand, people with bipolar depression may have their suicides attributed to unipolar major depression, in which case suicide risk in bipolar disorder may in fact be higher than previous estimates. Given this overall elevated risk, recent research has explored several facets of bipolar suicide risk. Suicide Risk Factors not Unique to Bipolar Disorder First, while it would be beyond the scope of this review to document all recent research on suicide, most risk factors for suicide in the general population also serve as risk factors for suicide among people with bipolar disorder. For example, one recent report from the Systematic Treatment Enhancement for Bipolar Disorder study (STEP-BD) investigated suicide events among 3,083 people diagnosed with bipolar disorder [23]. These suicide events included 140 attempts, of which eight were fatal. Consistent with the non-bipolar literature, the strongest predictor of a suicide event was a past history of suicide attempt (hazard ratio=2.60, p
