From the Guidelines
Primary care physicians treating bipolar disorder should be aware of several common comorbid conditions, including anxiety disorders, substance use disorders, attention-deficit/hyperactivity disorder (ADHD), and metabolic conditions like obesity, diabetes, and cardiovascular disease. These comorbidities can have a significant impact on the treatment and management of bipolar disorder, and regular screening is essential to identify them early on. Some of the key comorbid conditions to consider include:
- Anxiety disorders, such as generalized anxiety disorder and panic disorder
- Substance use disorders, particularly alcohol and cannabis use disorders
- Attention-deficit/hyperactivity disorder (ADHD)
- Metabolic conditions, including obesity, diabetes, and cardiovascular disease
- Thyroid disorders
- Migraines
- Sleep disorders, particularly insomnia
- Chronic pain conditions
- Metabolic syndrome, which can develop as a side effect of many mood stabilizers and antipsychotics used to treat bipolar disorder
When prescribing medications like lithium, valproate, or second-generation antipsychotics, PCPs should monitor weight, blood glucose, lipid profiles, and blood pressure regularly, as these medications can increase the risk of metabolic syndrome and other metabolic conditions 1. Additionally, PCPs should assess suicide risk at each visit, as bipolar disorder carries a significantly elevated suicide risk compared to the general population. The presence of these comorbidities often necessitates adjustments to medication choices and dosing strategies to avoid exacerbating existing conditions or creating harmful drug interactions.
It's also important to note that the treatment of bipolar disorder should be individualized and take into account the patient's specific needs and comorbidities. A comprehensive treatment plan should include regular monitoring of the patient's condition, as well as adjustments to the treatment plan as needed. By being aware of the common comorbid conditions associated with bipolar disorder and taking a comprehensive approach to treatment, PCPs can help improve outcomes and quality of life for their patients.
From the FDA Drug Label
Screening Patients for Bipolar Disorder: A major depressive episode may be the initial presentation of bipolar disorder It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown However, prior to initiating treatment with an antidepressant, including quetiapine, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.
When treating bipolar disorder, a primary care physician (PCP) should be aware of the following comorbid conditions:
- Diabetes mellitus: as patients with bipolar disorder are at a higher risk of developing diabetes, especially when treated with atypical antipsychotics like quetiapine 2 and olanzapine 3
- Dyslipidemia: as atypical antipsychotics have been associated with metabolic changes, including dyslipidemia 2 3
- Weight gain: as atypical antipsychotics have been associated with weight gain, which can increase the risk of other comorbid conditions like diabetes and cardiovascular disease 2 3
- Cerebrovascular adverse reactions: including stroke, in elderly patients with dementia-related psychosis, as seen with olanzapine 3
- Neuroleptic malignant syndrome (NMS): a potentially fatal symptom complex that can occur with antipsychotic treatment, including quetiapine 2 and olanzapine 3
- Drug reaction with eosinophilia and systemic symptoms (DRESS): a potentially fatal condition that can occur with olanzapine treatment 3
From the Research
Comorbid Conditions in Bipolar Disorder
When treating bipolar disorder, primary care physicians (PCPs) should be aware of several comorbid conditions, including:
- Psychiatric comorbidities such as anxiety, substance use disorders, and other mental health disorders 4, 5
- Medical comorbidities such as metabolic syndrome, which is present in 8-56% of patients with bipolar disorder 6
- Chronic medical illnesses, which are more common in individuals with bipolar disorder 5
- Cardiovascular disease, which is associated with an elevated risk in patients with bipolar disorder 7
Considerations for PCPs
PCPs should consider the following when treating patients with bipolar disorder:
- Screening for comorbid conditions, such as metabolic syndrome and substance use disorders 6, 5
- Monitoring for suicidal ideation, treatment adherence, and medical complications of pharmacotherapy 5
- Providing psychoeducation for patients and their support systems about the chronic nature of the illness, possible relapse, and environmental triggers 5
- Deciding what level of intervention their practice can support and potentially training office staff, setting up monitoring and follow-up systems, and establishing links with referral and community support services 4