Treatment of bipolarity + medical comorbidity = costability

An editorial comment to Magalhaes PV, Kapczinski F, Nierenberg AA, Deckersback T, Weisinger D, Dodd S, Berk M. Illness burden and medical comorbidity in the Systemic Treatment Enhancement Program for Bipolar Disorder (1)


This issue of the Acta Psychiatrica Scandinavica reports from an open-label follow-up of 3766 research subjects of the STEP-Bipolar project. At least one medical comorbid condition was found in 58.8%. Baseline data from subjects with bipolar-spectrum disorder and schizoaffective disorder, bipolar type, were analyzed retrospectively to determine the association of historical variables with medical comorbidity (1).

A strong linear-by-linear association was noted between the following historical variables and prevalence of any medical comorbidity:

  • i) More than 10 previous mood episodes;
  • ii) Childhood onset;
  • iii) Smoking;
  • iv) Lifetime of anxiety and substance use disorder.

In summary, this study (1) adds support to the notion that medical comorbidity may be a central aspect of the pathophysiology of the bipolar affective disorder spectrum, rather than the result of lifestyle and/or psychotropic medication.

This is consistent with prior research that suggests a diathesis toward medical comorbidity in bipolar disorder (2). Pirraglia et al. (2) found that the outcome of bipolar affective disorder correlated with stress and the experience of burden of total physical illness over time – rather than with a simple count of current medical diseases.

The authors of the current study (1) offer their interpretation that recurrent severe mood episodes may:

  • i) Promote additive allostatic stress leading to increased prevalence of medical illness and/or;
  • ii) Share an underlying physiological pathway with chronic medical illness, thereby increasing risk of both psychiatric and medical morbidity.

This research (1) has clinical implications that extend beyond what its title suggests. Because the diagnosis of schizoaffective disorder, bipolar type, was included in the study population, the findings may apply to other affective psychiatric conditions. Similar results have been found for other affective disorders. One study, for example, reported that endocrine/metabolic illness was associated with greater depressive symptom severity and poorer treatment outcomes.

Therefore, the take-home message, especially relevant to psychiatric and primary care providers, is to pay attention to three easily-overlooked areas of practice. These clinical domains have the potential to improve the outcome of, and/or minimize the severity of, medical conditions that may accompany exacerbations of chronic, recurring affective disorders:

  • Compliance: Non-adherence to medications for bipolar affective disorder and related affective conditions has been found to contribute – albeit at a barely significant level – to greater physical comorbidity in bipolar patients, as measured by the PCS (Physical Component Scale) (3). Providers should encourage implementation and maintenance of systems of medication delivery which ensure compliance in patients with bipolar-spectrum affective disorders.

  • Early intervention: Untreated or poorly treated affective disorders may contribute to the recurrence of, and/or chronicity of, medical comorbid conditions and vice versa. For example, medical conditions were more prevalent in a group of primary care patients with a recurrent depressive episode than in a group with a first episode of depressive disorder. Early medical intervention and consultation from specialists may, for affective disorder patients with medical comorbidities, help prevent worsening and recurrence of both conditions.

  • Prescribing practices: The geriatric proportion of the total population is growing, along with a concomitant increased burden of comorbid medical and psychiatric conditions. Risks inherent in prescribing medication combinations to the aged are obvious. As a result, there has been increased attention in the professional literature to pharmacokinetic/pharmacodynamic principles, parsimonious use of medications, and vigilance toward drug–drug interaction for the geriatric patient (4). Related issues have been raised in a recent article advocating more conservative prescribing principles (5).

In sum, the paper reviewed here has inherent recommendations that have the potential to improve the treatment of chronic medical conditions in affective disorders beyond the bipolar patient.