Bipolar disorder (BD) is associated with substantial functional impairment, high health care costs, and premature mortality. The World Health Organization (WHO) ranks BD in the top 10 causes of global disability and premature mortality.1 The morbidity, mortality, and personal suffering associated with BD are not simply the result of psychiatric symptoms, but are also the consequence of a wide range of comorbid medical disorders. The study from Gomes et al. complements a wide array of worldwide studies pointing to the high burden of cardiovascular disease (CVD) risk factors in BD in developed countries. Globally, over 80% of patients with BD have some degree of medical comorbidity,2,3 with the vast majority suffering or dying from CVD. The toll of the high rate of medical burden for patients with BD is not only premature mortality, but also worse prognosis with less favorable response to treatment, lower psychosocial functioning, higher rates of unemployment and, thus, a higher overall higher societal cost.4,5 Nevertheless, one aspect that has not yet entirely permeated the culture of health policy makers is the notion that patients with BD have even higher rates of medical comorbidities than those reported for other severe psychiatric disorders such as schizophrenia. In fact, in most health care settings, integrating psychiatric care with medical care and prevention is still a challenge.
Most implicated in the rampant increase in CVD risk in BD are the widespread use of atypical antipsychotics and the sedentary lifestyle and high-fat diet that prevail in most developed countries. Yet some lines of evidence suggest that cultural and environmental factors account for only part of the problem. This new report by Gomes et al. provides a snapshot of BD-associated CVD risk in developing countries and contributes to the evidence that medical burden - and, more specifically, cardiovascular burden - tends to be higher among patients with BD than in the surrounding general population in a wide variety of geographical contexts, across urban and rural settings, widely different cultural and lifestyle characteristics, and different prescribing practices.
We now have enough evidence to lay the groundwork for two main future developments: on one hand, clinicians and administrators need to develop ways to better integrate prevention and treatment of cardiovascular risk factors and diseases in mental health care settings. On the other, research into the root causes of cardiovascular risk in persons with serious mental illness needs to undertake a more critical approach and uncover those pathways to CVD in BD that go beyond lifestyle factors and medications.