Prevalence, chronicity, burden and borders of bipolar disorder

University of Siena, Department of Molecular Medicine and Clinical (DAI) Department of Mental Health, Viale Bracci 1, Siena 53100, Italy. Electronic address: .
Journal of Affective Disorders (Impact Factor: 3.38). 03/2013; 148(2-3). DOI: 10.1016/j.jad.2013.02.001
Source: PubMed


Bipolar disorder (BD) has traditionally been thought of as an episodic condition, characterized by periods of hypomania/mania and depression. However, evidence is accumulating to suggest that this condition is associated with significant chronicity. For a large proportion of patients with BD, residual, sub-syndromal symptoms persist between major syndromal episodes, and studies have shown that many patients with bipolar disorder are symptomatic for approximately 50% of the time over follow-up periods of greater than 10 years. Moreover, while the prevalence of BD has been estimated to be around 1-2%, there is growing evidence that this may be a substantial underestimation. There are a number of reasons for this potential underestimation, including difficulties in diagnosis. Adding to the burden of BD is the issue of comorbidity, with an increased prevalence of many chronic conditions in those with a primary diagnosis of BD. Conversely, for many patients with chronic conditions, both medical and psychiatric, BD frequently exists as a comorbid secondary diagnosis. This issue of comorbidity complicates estimates of use of pharmaceutical agents for BD, such as mood stabilizers, which are known to be used off-label in conditions such as borderline personality or substance use disorder. We speculate that such off-label prescribing may not be truly off-label but may be instead fully justified by an overlooked secondary diagnosis of BD. Finally, we discuss the association of bipolar disorder with a significant economic burden, to the individual and to society, both due to the direct costs of medical expenditure and indirect costs such as loss of productivity and increased mortality.

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Available from: Alessandro Rossi, Oct 10, 2014
    • "Bipolar disorder (BD) is a highly prevalent and disabling illness associated with significant morbidity and mortality (Kupfer, 2005;Fagiolini et al., 2013). In the last twenty years, cognitive deficits have been well established as a core characteristic of BD and have been recognized as an important predictor of functional impairment in personal, occupational and social domains (Green, 2006;Tse et al., 2014). "
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    ABSTRACT: Background: Bipolar disorder (BD) has been associated with cognitive impairment during depressed, manic and euthymic periods. Inflammation has been shown to be involved in the pathophysiology of BD and cognitive impairment. Methods: For this systematic review, the MEDLINE/PubMed, Embase, Google Scholar and databases were searched for relevant articles assessing the association between cognitive function and inflammatory markers in BD subjects. A discussion of potential mechanisms and therapeutic implications is also included to provide further context to the subject matter. Results: Eight studies, including a total of 555 BD subjects, assessing the association between cognitive function and inflammatory markers were identified. Cognitive dysfunction was associated with elevated levels of pro-inflammatory markers YKL40, IL-6, sCD40L, IL-1Ra, hsCRP and TNF-α. Mechanistically, elevation in inflammatory cytokines alters monoamine levels leading to cognitive and affective dysfunction. Neuro-inflammation, manifesting as microglial activation, leads to increased oxidative stress, pathologic synaptic pruning and impaired neuroplasticity in key brain regions sub-serving mood and cognition. Immune dysfunction also activates the hypothalamic-pituitary-adrenal (HPA) axis leading to hypercortisolemia and metabolic dysfunction, further promoting neuronal dysfunction. Anti-inflammatory agents are therefore currently being investigated in the treatment of BD and appear to exert an antidepressant effect; however, cognitive outcomes have yet to be reported. Conclusion: Several studies suggest that immune dysfunction is associated with cognitive impairment in BD. Several neurobiological pathways have been identified whereby immune dysfunction may promote cognitive impairment in BD. Future investigations of anti-inflammatory agents targeting cognitive function as a treatment outcome are merited.
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    • "The prevalence of bipolar I disorder in Italy is estimated to be approximately 1–2%, even if the true prevalence is likely to be much higher because it is frequently under-diagnosed, largely due to the fact that it is difficult to diagnose correctly [2]. Because bipolar disorder is one of the leading causes of disability, especially in active populations, it represents an important economic burden on society [3]. "
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    ABSTRACT: Introduction: Bipolar disorder is a chronic disease characterized by periods of mania or hypomania, depression, or a combination of both (mixed state). Because bipolar disorder is one of the leading causes of disability, it represents an important economic burden on society. Asenapine (ASE) is a new second-generation antipsychotic developed and approved for the treatment of manic or mixed episodes associated with bipolar disorder. The objective of the present study was to assess the cost-effectiveness of ASE compared to olanzapine (OLA) in the treatment of patients experiencing mixed episodes associated with bipolar I disorder in the context of the Italian National Health Service (NHS). Methods: A pharmacoeconomic model was developed to simulate the management of Italian bipolar I patients with mixed episodes over a 5-year time horizon by combining clinical parameters with resource utilization. An expert panel of Italian psychiatrists and health economists was responsible for adapting a UK model to the Italian context. The primary outcome measure of the economic evaluation was the incremental cost effectiveness ratio, where effectiveness is measured in terms of quality adjusted life-years gained. Scenario analyses, sensitivity analyses, and a probabilistic sensitivity analysis were performed to test the robustness of the model. Results: This pharmacoeconomic model showed that ASE resulted to be dominant over OLA; in fact, ASE was associated with lower direct costs (derived largely by the savings from hospitalizations avoided) and also generated a better quality of life. Results were robust to changes in key parameters; both scenario analyses and sensitivity analyses demonstrated model reliability. Conclusions: Results from this study suggest that the management of bipolar I patients with mixed episodes using ASE as alternative to OLA can lead to cost saving for the Italian NHS and improve patients quality of life.
    Full-text · Article · Jul 2014 · Advances in Therapy
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    • "In adults with bipolar spectrum disorder, high rates of comorbidity for anxiety disorders, substance abuse and personality disorders are reported [29-37]. Recent data also suggest increased comorbid substance/alcohol abuse and anxiety in adults with MDD and subsyndromal hypomanic features, compared to individuals with MDD without a history of subsyndromal hypomanic features [10,38]. "
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    ABSTRACT: We investigated whether adolescents with hypomania spectrum episodes have an excess risk of mental and physical morbidity in adulthood, as compared with adolescents exclusively reporting major depressive disorder (MDD) and controls without a history of adolescent mood disorders. A community sample of adolescents (N = 2 300) in the town of Uppsala, Sweden, was screened for depressive symptoms. Both participants with positive screening and matched controls (in total 631) were diagnostically interviewed. Ninety participants reported hypomania spectrum episodes (40 full-syndromal, 18 with brief episode, and 32 subsyndromal), while another 197 fulfilled the criteria for MDD without a history of a hypomania spectrum episode. A follow up after 15 years included a blinded diagnostic interview, a self-assessment of personality disorders, and national register data on prescription drugs and health services use. The participation rate at the follow-up interview was 71 % (64/90) for the hypomania spectrum group, and 65.9 % (130/197) for the MDD group. Multiple imputation was used to handle missing data. The outcomes of the hypomania spectrum group and the MDD group were similar regarding subsequent non-mood Axis I disorders in adulthood (present in 53 vs. 57 %). A personality disorder was reported by 29 % of the hypomania spectrum group and by 20 % of the MDD group, but a statistically significant difference was reached only for obsessive-compulsive personality disorder (24 vs. 14 %). In both groups, the risk of Axis I disorders and personality disorders in adulthood correlated with continuation of mood disorder. Prescription drugs and health service use in adulthood was similar in the two groups. Compared with adolescents without mood disorders, both groups had a higher subsequent risk of psychiatric morbidity, used more mental health care, and received more psychotropic drugs. Although adolescents with hypomania spectrum episodes and adolescents with MDD do not differ substantially in health outcomes, both groups are at increased risk for subsequent mental health problems. Thus, it is important to identify and treat children and adolescents with mood disorders, and carefully follow the continuing course.
    Full-text · Article · Jan 2014 · BMC Psychiatry
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