Bipolar disorder complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]
Overview
Lifelong outcome has rarely been studied, and precise data on the natural outcome are scarce. Some studies demonstrate that most patients continue to suffer from residual depressive or hypomanic symptoms between episodes, and many are functionally impaired. Bipolar disorder, has significant morbidity and mortality rates. Often, the cycling between depression and mania accelerates with age. The main complications of bipolar disorder are suicide, homicide, and addictions.
Natural History
- In bipolar disorder the lifetime proportions of mania and depression remain stable into old age. Bipolar female subjects manifest more depression than bipolar male; and they have a poorer prognosis than other bipolar conditions, with slower remissions and higher risk for chronicity.[1]
- The natural length of bipolar disorder episode has not changed over the past 120 years. Patients responding to antidepressants still require a maintenance treatment throughout the underlying episode. The median length of episodes is 3 to 6 months. The recurrence of bipolar disorder is the rule; there is some initial shortening of intervals/cycles, followed by an irregular persistent recurrence, with a median cycling of 18 months.[2]
- Lifelong outcome has rarely been studied, and precise data on the natural outcome are scarce. Some studies demonstrate that most patients continue to suffer from residual depressive or hypomanic symptoms between episodes, and many are functionally impaired.[1]
- The natural history of bipolar illness shows that it has a poor prognosis, as reflected by high recurrence, chronicity of episodes and premature death by suicide and somatic disorders.[1]
Complications
- Stopping medication or taking it the wrong way can cause your symptoms to come back, and lead to the following complications:
- Alcohol and/or drug abuse
- Problems with relationships, work, and finances
- Suicidal thoughts and behaviors, suicidal patients remain at risk for suicide. Patients emerging from a depression are thought to be at an increased risk for suicide. men with bipolar disorder are at higher risk for suicide.[3]
- Homicide often in the manic phase can be very demanding and grandiose. These individuals can become homicidal by acting on delusions.
- Bipolar disorder type I results in diminished quality of life as measured by health utility and utility-based health-related quality of life. The patients with depression sustained the greatest loss in QOL.[4]
Prognosis
A good prognosis results from good treatment, which, in turn, results from an accurate diagnosis. Because bipolar disorder continues to have a high rate of both under-diagnosis and misdiagnosis, it is often difficult for individuals with the condition to receive timely and competent treatment.
Bipolar disorder can be a severely disabling medical condition. However, with appropriate treatment, many individuals with bipolar disorder can live full and satisfying lives. Persons with bipolar disorder are likely to have periods of normal or near normal functioning between episodes.
Ultimately one's prognosis depends on many factors, which are, in fact, under the individual's control: the right medicines; the right dose of each; a very informed patient; a good working relationship with a competent medical doctor; a competent, supportive and warm therapist; a supportive family or significant other; and a balanced lifestyle including a regulated stress level, regular exercise and regular sleep and wake times.
There are obviously other factors that lead to a good prognosis as well, such as being very aware of small changes in one's energy, mood, sleep and eating behaviors, as well as having a plan in conjunction with one's doctor for how to manage subtle changes that might indicate the beginning of a mood swing. Some people find that keeping a log of their moods can assist them in predicting changes.
Recurrence
Even when on medication, some people may still experience weaker episodes, or have a complete manic or depressive episode. In fact, a recent study found bipolar disorder to be "characterized by a low rate of recovery, a high rate of recurrence, and poor interepisodic functioning." Worse, the study confirmed the seriousness of the disorder as "the standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold." Bipolar disorder is currently regarded "as possibly the most costly category of mental disorders in the United States."[5]
The following behaviors can lead to depressive or manic recurrence:
- Discontinuing or lowering one's dose of medication, without consulting one's physician.
- Being under- or over-medicated. Generally, taking a lower dosage of a mood stabilizer can lead to relapse into mania. Taking a lower dosage of an antidepressant, may cause the patient to relapse into depression, while higher doses can cause destabilization into mixed-states or mania.
- Taking hard drugs—recreationally or not—such as cocaine, alcohol, amphetamines, or opiates. These can cause the condition to worsen.
- An inconsistent sleep schedule can destabilize the illness. Too much sleep (possibly caused by medication) can lead to depression, while too little sleep can lead to mixed states or mania.
- Caffeine can cause destabilization of mood toward irritability, dysphoria and mania. Anecdotal evidence seems to suggest that lower dosages of caffeine can have effects ranging from anti-depressant to mania-inducing.
- Inadequate stress management and poor lifestyle choices. If unmedicated, excessive stress can cause the individual to relapse. Medication raises the stress threshold somewhat, but too much stress still causes relapse.
- Often bipolar individuals are subject to self-medication, the most common drugs being alcohol, and marijuana. Sometimes they may also turn to hard drugs. Studies show that tobacco smoking induces a calming effect on most bipolar people, and a very high percentage suffering from the disorder smoke. [3]
Recurrence can be managed by the sufferer with the help of a close friend, based on the occurrence of idiosyncratic prodromal events.[6] This theorizes that a close friend could notice which moods, activities, behaviours, thinking processes, or thoughts typically occur at the outset of bipolar episodes. They can then take planned steps to slow or reverse the onset of illness, or take action to prevent the episode from being damaging. [7]
Mortality
"Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD. The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder."[8]
Although many people with bipolar disorder who attempt suicide never actually complete it, the annual average suicide rate in males and females with diagnosed bipolar disorder (0.4%) is 10 to more than 20 times that in the general population.[9]
Individuals with bipolar disorder tend to become suicidal, especially during mixed states such asdysphoric mania and agitated depression. Persons suffering from Bipolar II have high rates of suicide compared to persons suffering from other mental health conditions, including Major Depression. Major Depressive episodes are part of the Bipolar II experience, and there is evidence that sufferers of this disorder spend proportionally much more of their life in the depressive phase of the illness than their counterparts with Bipolar I Disorder (Akiskal & Kessler, 2007).
References
- ↑ 1.0 1.1 1.2 Angst, Jules; Sellaro, Robert (2000). "Historical perspectives and natural history of bipolar disorder". Biological Psychiatry. 48 (6): 445–457. doi:10.1016/S0006-3223(00)00909-4. ISSN 0006-3223.
- ↑ Angst, Jules; Sellaro, Robert (2000). "Historical perspectives and natural history of bipolar disorder". Biological Psychiatry. 48 (6): 445–457. doi:10.1016/S0006-3223(00)00909-4. ISSN 0006-3223.
- ↑ Ilgen MA, Bohnert AS, Ignacio RV, McCarthy JF, Valenstein MM, Kim HM; et al. (2010). "Psychiatric diagnoses and risk of suicide in veterans". Arch Gen Psychiatry. 67 (11): 1152–8. doi:10.1001/archgenpsychiatry.2010.129. PMID 21041616.
- ↑ Saarni SI, Viertiö S, Perälä J, Koskinen S, Lönnqvist J, Suvisaari J (2010). "Quality of life of people with schizophrenia, bipolar disorder and other psychotic disorders". Br J Psychiatry. 197 (5): 386–94. doi:10.1192/bjp.bp.109.076489. PMID 21037216.
- ↑ Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski "Bipolar Disorder: Defining Remission and Selecting Treatment" Vol. XXIII, No. 11 (October 2006)
- ↑ Perry A, Tarrier N, Morriss R, McCarthy E, Limb K “Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of recurrence and obtain treatment” BMJ 1999;318:149-153 (16 January)
- ↑ Kelly, M., Bipolar and the Art of Roller-coaster Riding, Two Trees Media 2000, 2005
- ↑ Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski. "Bipolar Disorder: Defining Remission and Selecting Treatment". Psychiatric Times, October 2006, Vol. XXIII, No. 11.
- ↑ Leslie Citrome, MD, MPH; Joseph F. Goldberg, MD. "Bipolar disorder is a potentially fatal disease".