Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Abstract
The two most common bipolar disorders are
bipolar I disorder and bipolar II disorder. Comorbid psychiatric disorders
usually precede the onset of bipolar disorder. Bipolar disorder often coexists
with other Axis I and Axis II disorders. Studies have shown that patients with
mood disorders have more comorbid medical illnesses. Research has suggested
that that there may be underlying biological mechanisms linking mood disorder
and many medical illnesses.The current study will determine the psychiatric and
medical disorders in a sample of patients with bipolar affective disorder in a
general hospital setting.
Aims and Objectivest: study the
socio-demographic profile of patients with Bipolar affective disorder, to study
the prevalence of psychiatric comorbidities in patients with Bipolar affective
disorder and to study the prevalence of medical comorbidities in patients with
Bipolar affective disorder.
Methodology: This
cross-sectional study was conducted at the department of Psychiatry,
Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Medical College and
hospital, Bemina, Srinagar, Jammu and Kashmir. Psychiatry department at
SKIMS-MC is a General Hospital Psychiatry unit.
Results: In the present
study the mean age of patients was 34.3 years, Majority of patients were
females, married. In this study, obesity/ weight gain (n=52), chronic headache
(n=45), hypertension (n=30), elevated serum lipids (n=28), thyroid disorders
(n=19), diabetes (n=12), GERD (n=9), CAD (n=4), epilepsy (n=2), COPD (n=2),
bronchial Asthma (n=1), Parkinson’s disease (n=1), CKD (n=1) were among the
medical comorbidities. In this study the most prevalent psychiatric disorders
in patients with BPAD were Substance use disorder (n=32), somatoform disorders
(n=18), Generalized anxiety disorder (n=12), obsessive and compulsive disorder
(n=11), panic disorder (n=9), simple phobia (n=7), eating disorders (n=5),
social phobia (n=4), and PTSD (n=2).
Conclusion: The current study
suggested that patient suffering from bipolar affective disorder are at increased
risk of developing medical or psychiatric comorbidities. It is very important
for the treating physician to be aware of the prevalent medical and psychiatric
conditions patients with bipolar affective disorders and knowledge of these
comorbidities help in prevention, early detection and treatment of such
illnesses as well will improve treatment response and prognosis in bipolar
patients itself. Awareness among healthcare professionals about the risks to
which patients withaffective disorders are exposed is of great importance, as
the medical illnessesare likely to coexist with a mood disorder, which may help
to improvediagnostics and management and therefore clinical and social care for
patients. Overall, the presence of comorbidities in BPD has negative prognostic
implications for psychological health and for medical well-being and longevity.
In order to improve quality of life, prognosis and life expectancy for those
with these illnesses, it is important that further researches on this topic should
be continued.
Keywords: Bipolar Disorder; Psychiatric
Comorbidity; Medical Comorbidity; Anxiety Disorders; Substance Abuse
Background
A complex, chronic mood disorder
involving repeated episodes of depression and mania/hypomania is referred as
Bipolar disorder [1]. The two most common bipolar disorders are bipolar I
disorder and bipolar II disorder. The lifetime prevalence of MDD Is around
12.2% to 16.2% [2,3] while as the prevalence of bipolar disorder are
significantly lower, ranging from 0.9% to 4.4% [4,5]. In Bipolar disorder I
prevalence has been found to range from 0.8% to 3.3% [6,7] while as in Bipolar
disorder II prevalence has been estimated at around 0.5% to 1.1% [8] The
presence of more than one disorder in a person, for a defined period of time is
referred as Comorbidity[9] Comorbidity can be of three main types:[10]
1. Comorbidity of physical and
psychiatric disorders, e.g. depression and hyperthyroidism;
2. Comorbidity of related disorders, e.g.
anxiety and depression; and
3. Comorbidityof disorders indirectly
related, e.g. psychotic depression and substance abuse.
Comorbid psychiatric disorders usually
precede the onset of bipolar disorder. Bipolar disorder often coexists with
other Axis I and Axis II disordersand studies have found that psychiatric
comorbidity in bipolar disorder range from 50% to 70% [11], In a Study with
bipolar disorder, 65% patients met DSM-IV criteria for at least 1 comorbid
lifetime Axis I disorder, whereas 42% had 2 or more Axis I comorbidities, and
24% had 3 or more [12]. Bipolar patients with psychiatric comorbidity had more
mixed features, depressive episodes, and suicide attempts; poorer outcome and
treatment compliance [10]. In another study, substance use disorders also
follow the onset of bipolar disorder [13]. Sixty percent of premature deaths in
those with serious mental illness are as a result of general medical conditions
[14]. Studies have shown that patients with mood disorders have more comorbid
medical illnesses. Researchhas suggested that that there may be underlying
biological mechanisms linking mood disorder and many medical illnesses [15-18].
The current study will determine the
psychiatric and medical disorders in a sample of patients with bipolar
affective disorder in a general hospital setting.
Aims and Objectives
a) To study the socio-demographic profile
of patients with Bipolar affective disorder.
b) To study the prevalence of psychiatric
comorbidities in patients with Bipolar affective disorder.
c) To study the prevalence of medical
comorbidities in patients with Bipolar affective disorder.
Material and Methods
This cross-sectionalstudy was conducted
at the department of Psychiatry, Sher-I-Kashmir Institute of Medical
Sciences(SKIMS),Medical College and hospital, Bemina, Srinagar, Jammu and
Kashmir. Psychiatry department at SKIMS-MC is a General Hospital Psychiatry
unit. The study was approved by institutional ethical committee.
The patients attending the hospital
outpatient department giving a voluntary consent were included in the study.
The present study was conducted on patients with bipolar affective disorder.
The sample comprised 100 patients attending psychiatry OPD diagnosed as Bipolar
Affective Disorder using ICD 10 during the period of june 2017 to june 2018
[19]. The diagnosis for the study group was confirmed by M.I.N.I (Mini
International Neuropsychiatric Interview) [20]. The following inclusion and
exclusion criteria were used in the study.
Inclusion Criteria for patient:
a) Patients should fulfill ICD -10
criteria for Bipolar affective disorder.
b) Age of the patient should be 18 years
or above.
c) Illness duration of at least 12
months.
d) Patients who are able to provide
informed consent.
Exclusion Criteria for patient:
a) Patients aging below 18 years of age.
b) Patients who are not willing to
participate.
c) Patients who had medical or
psychiatric illness before the diagnosis of BPAD.
Methodology
Instruments:
a) Demographic profile and clinical data
sheet of patients. Intake data of each patient was recorded on a specially
designed proforma. This consisted of details about age, sex, marital status,
educational status, occupation, socioeconomic status, residence, type of
family.
b) International Classification of Mental
and Behavioral Disorders (ICD-10)
[19] Based on the clinical assessment,
the diagnosis was made according to ICD-10 clinical descriptions and diagnostic
guidelines.
c) Mini-International Neuropsychiatric
Interview (M.I.N.I) [20]
The Mini-International Neuropsychiatric
Interview (M.I.N.I.) is a short structured diagnostic interview, developed
jointly by psychiatrists and clinicians in the United States and Europe, for
DSM-IV and ICD-10 psychiatric disorders.
Results
In the present study the mean age of
patients was 34.3 years, Majority of patients i.e. 31% (n=31) were from 30-39
years of age group followed by 26% (n=26) of patients in the age group of 20-29
years ,17% (n=17) in ≥ 50 years,14% (n=14) in the age group of 40-49years and
12% (n=12) < 20years. Majority of BPAD patients were females i.e. 53% (n=53)
and males were 47% (n= 47). Among 100 patients most of them were married 63%
(n=63) and 37% (n= 37) were unmarried with no formal education i.e. 36% (n=36)
, 32% (n=32%) had secondary education, 26% (n=26) were graduate and 6% (n=6)
had primary education. Majority of the patient in our study belonged to low
socioeconomic status i.e.60% (n= 60) and 40% (n=40) belonged to middle
socioeconomic status. Most of patients i.e. 86% (n=86) had rural residence and
14% (n=14) had urban residence (Tables 1-5) and (Figure 1).
In 82% (n=82) of patients there was no
family history of psychiatric illness and in 18% (n=18) of patients, mental
illness in any other family member was present. In present study, 87% (n=87) of
patients, no medical illness was present in family member and 13% (n=13) of
patients had medical illness present in family In this study, obesity/ weight
gain (n=52), chronic headache (n=45), hypertension (n=30), elevated serum
lipids (n=28), thyroid disorders (n=19), diabetes (n=12), GERD (n=9), CAD
(n=4), epilepsy (n=2), COPD (n=2), bronchial Asthma (n=1), Parkinson’s disease
(n=1), CKD (n=1) were among the medical comorbidities. In this study the most
prevalent psychiatric disorders in patients with BPAD were Substance use
disorder (n=32), somatoform disorders (n=18), Generalized anxiety disorder
(n=12), obsessive and compulsive disorder (n=11), panic disorder (n=9), simple
phobia (n=7), eating disorders (n=5), social phobia (n=4), and PTSD (n=2).
Discussion
This study examined the Medical and
psychiatric comorbidity in patients with Bipolar Disorder. Bipolar disorder
(BPD) is highly prevalent disorder by the presence of comorbid conditions and
these comorbidities has negative prognostic implications for psychological and
medical well-being and longevity.[16,17] Bipolar disorders are associated with
psychiatric and medical comorbidities and simultaneous diagnosis and their
treatment is equally important [21,22]. Most patients suffering from bipolar
disorder met criteria for 3 or more lifetime psychiatric disorders. Patients
with bipolar disorder has impairment even during the period of remission due to
physical and psychiatric comorbidities and can lead to disability. WHO
classification of disability have placed BPD seventh in the disability cause
[23-26], The complex mechanisms underlying the comorbidity in Bipolar disorders
may suggest that the causal relationships are likely to be bidirectional
[27,28].
In our sample the medical conditions
associated with bipolar disorder were Obesity/weight gain(52%), Headache (45%),
Hypertension (30%), Elevated serum lipids (28%), Thyroid disorders (19%),
Diabetes (12%), GERD (9%), Coronary artery disease (4%), Epilepsy and COPD 2%
each, Parkinson’s disease, Bronchial Asthma, and chronic kidney disease 1 %
each.
Burden of overweight has increased
rapidly over the past decades globally. Obesity/Overweight are emerging as an
important public health problem in India [29,30]. In India reported prevalence
of overweight in range of 1.5%–24.0%in general population and showed rapid
increase [31]. In our study the 53% patients showed weight gain which is higher
than the prevalence in general population, Patients with Bipolar disorder tend
to be overweight and reason could be the treatment of bipolar disorder
especially valproate, carbamazepine, Lithium and antipsychotics which may also
increase the risk of other comorbid medical disease [32-36].
Another reason for could be the comorbid
eating disorder which includes the excessive carbohydrate consumption and low
rates of exercise [37,38]. Headache is prevalent in every country affecting
both genders and all socioeconomic levels. In general the percentages of the
adult population with an active headache is 46% [41,42].
In our study 47% patients were suffering
from headaches which is almost similar to the prevalence of general population.
The connection between migraines and bipolar disorder is so strong that over
one-third of people living with bipolar suffer from migraines [43,44].
Researchers think that there may be a genetic abnormality in serotonin,
dopamine and glutamine neurotransmitters that contributes to both migraine
headaches and bipolar disorder [45]. Hypertension is an important public health
problem in developed and developing nations [46,47].The prevalence of hypertension
in general population is 20.9% and in our study 30% patients with BPAD was
suffering from hypertension which is higher than the general population [48].
The link between bipolar affective disorder and hypertension depends upon
various factors such as Life styles, obesity and psychotropic medicines in
particular second-generation antipsychotics are likely to play a role [49-51].
The effect of psychotropic medications
and associated weight gain or the complications of treatment with some atypical
antipsychotics may lead to diabetes as well as a marked increase of serum
lipids [52]. A bipolar disorder and metabolic disorders, such as coronary
artery disease and diabetes type 2, have strong genetic links and may share
some common pathophysiological pathways [53]. The comorbidity of thyroid
disorder in individuals with bipolar disorders has a well-established link.
Lithium a mood stabilizer which is a common treatment for bipolar disorder can
also lead to thyroid disorders as a common side-effect of the drug [54]. A
higher burden of medical illness is indicative of a more severe illness course,
with greater impairment in functioning which has been also seen in previously
reported findings.The presence of a medical condition increases the risk of
developing a mood episode/ disorder and vice versa [49]. Bipolar disorder often
coexists with other Axis I disorders.In our study the psychiatric disorders
associated with bipolar affective disorders were Substance use disorder (32%),
somatoform disorders (18%), Generalized anxiety disorder (12%), obsessive and
compulsive disorder (11%), panic disorder (9%), simple phobia (7%8), eating
disorders (5%), social phobia (4%), and PTSD (2%).
Psychiatric disorders with bipolar
disorder compared to their rates in the general population are higher and can
pose a therapeutic challenge as well as a diagnostic dilemma [55]. A careful
assessment, accurate history form bipolar patient is a challenge due to overlap
between symptoms of BPAD and other psychiatric conditions.
Comorbid Substance use disorder was found
to exist in 48- 61% of patients with bipolar affective disorder in some studies
[56-58]. The significant indicator for the course of bipolar disorderisdrug
abusewith regard to the individual and in relation to family history of drug
abuse. Patients with bipolar affective disorder are at higher risk for anxiety
disorders including generalized anxiety disorder, simple phobia, social phobia,
obsessive-compulsive disorder, posttraumatic stress disorder, and panic
disorder [59,60]. Substance use and anxiety disorders are higher in patients
with bipolar disorder than in general population, similar results were found in
our study [61,62].
Conclusion
The current study suggested that patient
suffering from bipolar affective disorder are at increased risk of developing
medical or psychiatric comorbidities. It is very important for the treating
physician to be aware of the prevalent medical and psychiatric conditions
patients with bipolar affective disorders and knowledge of these comorbidities
help in prevention, early detection and treatment of such illnesses as well
will improve treatment response and prognosis in bipolar patients
itself.Awareness among healthcare professionals about the risks to which
patients withaffective disorders are exposed is of great importance, as the
medical illnessesare likely to coexist with a mood disorder, which may help to
improvediagnostics and management and therefore clinical and social carefor
patients. Overall, the presence of comorbidities in BPD has negative prognostic
implications for psychological health and for medical well-being and longevity.
In order to improve quality of life, prognosis and life expectancy for those
with these illnesses, it is important that further researches on this topic
should be continued.
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