Bipolar Disorder Is Associated With Premature Mortality

Bipolar disorder (previously called manic-depressive illness) is a serious mental illness marked by manic episodes and, usually, depressive episodes. Symptoms involve severe fluctuations in mood, cognition, energy, and activity levels.

It is estimated that about one percent of the population suffers from bipolar disorder, and the illness is associated with disruption of relationships, employment, and everyday functioning. In addition, bipolar disorder has been increasingly associated with premature death.

How extensive is this premature mortality and what accounts for it? These questions are explored in a recent analysis published by Tais Boeira Biazus and colleagues in the journal Molecular Psychiatry.

Biazus and colleagues conducted a systematic review and meta-analysis of previously published research regarding mortality in people with bipolar disorder as compared to appropriate control populations. By using specific quality criteria, they combined data from 57 unique studies involving 678,353 persons with bipolar disorder. Individuals in these studies came from 16 different countries, mostly in Western Europe, the United States, and Asia.

Overall, the relative risk of death for individuals with bipolar disorder was 2.02, meaning that individuals with this disorder were about twice as likely to die in a given period of time as individuals without the disorder.

The Biazus team conducted additional analyses to investigate specific causes of death. They found that the relative risk of death from suicide and other unnatural causes (such as accidents, overdoses, and violence) is markedly increased. The relative risk from suicide is about 11.6, whereas the relative risk of dying from unnatural causes is about 7.3.

Why Does Bipolar Disorder Increase the Risk of Death?

Bipolar disorder can be psychologically devastating, leading persons to take their own lives or act in ways that increase the risks of death from unnatural causes. Women with bipolar disorder have a 20 percent higher risk of suicide than men with the disorder. This contrasts with the difference in suicide rates in those with depressive disorder where the rate is much higher in men than women.

Although dramatic, deaths resulting from suicides and other unnatural causes do not entirely account for the 2-fold increase in premature death. So what does?

The risk of a person with bipolar disorder dying prematurely from infectious diseases is elevated over 4-fold, respiratory diseases over 3-fold, cardiovascular diseases 1.8-fold, and cerebrovascular diseases 1.6-fold. In contrast, the risk of a person with bipolar disorder dying from cancer is about the same as controls. The authors hypothesize that the increased risk for respiratory deaths might be related to the high rates of tobacco use in populations with bipolar disorder. It is likely that the increases in cardiovascular, cerebrovascular, infectious, and respiratory deaths are multifactorial.

What This Means for Treatment

These data have important clinical implications. Treatment of individuals with bipolar disorder necessarily includes addressing specific symptoms of the illness, but should also include encouraging healthy lifestyle changes involving diet, exercise, smoking cessation, avoiding drug and alcohol use, as well as management of blood pressure and obesity. Better symptomatic treatments together with emphasis on lifestyle changes may help to decrease deaths from both unnatural and natural causes.

Regarding pharmacologic treatments, many individuals with bipolar disorder do reasonably well with current medications such as lithium, mood-stabilizing anticonvulsants, and antipsychotics. Newer treatments are being investigated. Hopefully, more effective treatments with fewer side effects will increase the ability to help individuals with this disorder live longer and symptom-free lives.

This column was written by Eugene Rubin, M.D., Ph.D., and Charles Zorumski, M.D.