Co-prescription of medication for bipolar disorder and diabetes mellitus: a nationwide population-based study with focus on gender differences

Psychiatric factors predict type 2 diabetes mellitus in US Veterans

Co-occurrence of type 2 diabetes mellitus (T2D) and serious mental illnesses (SMI) is prevalent yet underappreciated, and significantly contributes to increased morbidity and reduced lifespan. There is, therefore, a need to identify T2D risk factors to inform preventative approaches to the care of SMI-diagnosed patients. Our objective was to use predictive modeling methods to capture risk factors for T2D in a sample of 618,203 Veterans using data obtained from hospital electronic health records (EHR). This case-control study assessed VISN4 Veterans with and without T2D diagnoses and SMI diagnoses (schizophrenia, SZ; schizoaffective, SZA; bipolar disorder, BD; major depression, MDD; 2009-2019). Demographic variables and medications were obtained from the EHR. Following rigorous data quality control, 543,979 Veterans qualified for analysis (Agemean[SD] = 65.9[17.6]years; body mass index(BMI)mean[SD] = 28.6[6.0]kg/m2; NT2D = 157,457[29%]; and Nmale = 506,257[93.1%]). Veterans with co-occurring SMI + T2D included NSZ = 2,087(36.5%), NSZA = 1,345(36.3%), NBD = 10,540(29.2%), and NMDD = 20,510(30%) compared to 112,973(28.6%) non-SMI controls (NSC) with T2D. Factors that predicted T2D (R2 = 34%) included age, sex, BMI, race/ethnicity, psychiatric diagnoses, and commonly prescribed psychiatric medications. Significant interactions were found between age (centered) and BMI on the odds of T2D (P < 0.001), as well as interaction between sex and BMI (P < 0.001), after adjusting for confounders. Veterans with SMI (SZ, MDD, SZA, and BD) had a higher likelihood of experiencing T2D, compared to the NSCs (ORSZ = 1.30, 95% CI = 1.21-1.40; ORMDD = 1.07, 95% CI = 1.05-1.10; ORSZA = 1.26, 95% CI = 1.16-1.38; ORBD = 1.05, 95% CI = 1.01-1.08). Finally, Veterans exposed to both selective serotonin reuptake inhibitor (SSRI) antidepressants and mood stabilizers had a 2.11 times increase in the odds of having T2D (95% CI = 2.06-2.16; P < 0.001) compared to Veterans not taking either medication. Four major psychiatric disorders (SZ, SZA, MDD, and BD) and several classes of medications used to treat them increased T2D risk. Our findings suggest that the measures assayed offer a potentially useful signal, that along with clinical, anthropometric, and biochemical measures can be used to ascertain metabolic risk. If confirmed with an independent sample, these findings could also inform medication choices made by prescribers.

Cardiometabolic and endocrine comorbidities in women with bipolar disorder: A systematic review

INTRODUCTION

Bipolar Disorder (BD) is known to be equally distributed among males and females. The well-documented increased risk of medical comorbidities in patients with BD, in comparison to BD patients without medical comorbidities, shows a negative impact on the course of illness. There is some evidence suggesting that women with BD have higher psychiatric and medical comorbidities in comparison to men with BD, however there is no evidence in comparison to women without BD or other major psychiatric illness. These comorbidities, along with various psychosocial factors, are known to affect the course of BD.

METHODS

We aimed to systematically review the literature on cardiovascular, metabolic and endocrine comorbidities in women with BD in comparison to men with BD and control women. A comprehensive search of electronic databases including PubMed, PsycINFO, Embase, and SCOPUS was conducted, and a total of 61 identified studies were included in this review.

RESULTS

Women with BD had higher rates of cardiovascular risk factors/mortality, diabetes mellitus II and thyroid disorders compared to women in the general population. In comparison to men with BD, women with BD had comparable cardiovascular risk but higher prevalence of metabolic and thyroid disorders.

LIMITATIONS

Gender specific data was limited in multiple studies.

CONCLUSIONS

Results present a need for gender-specific screening and interventions for various medical comorbidities in patients with BD.

Using Lithium in Older Age Bipolar Disorder: Special Considerations

Lithium is the gold-standard treatment for bipolar disorder, and is effective in the management of manic, depressive, and maintenance phases of bipolar disorder treatment. Despite this, the implications of lithium use in the older population remain less understood. This critical narrative review aims to better understand the impact of lithium in older age bipolar disorder (OABD), including tolerability and efficacy, based on up-to-date evidence. Relevant studies of efficacy, effectiveness, and tolerability published any time prior to May 2018 were identified using the PubMed keyword search "lithium older adult bipolar disorder" and references from recent international bipolar disorder guidelines. One randomized controlled trial was identified, the GERI-BD (Acute Pharmacotherapy in Late-Life Mania) study. This study found lithium to be effective in late-life mania and hypomania. The remaining literature examining lithium in OABD was reviewed, comprising of a number of small open-label and retrospective studies, with special considerations highlighted. In summary, there is a small yet increasing geriatric evidence base that lithium is effective in OABD. Although there can be adverse effects with lithium, it is generally well tolerated, and there are methods to minimize these risks. Further research would strengthen the evidence base for lithium therapy in OABD. In the meantime, lithium remains the gold-standard treatment for OABD.

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

Comorbid Diabetes and Depression in a National Sample of Adults With Psychosis

Objective

People with psychosis have an elevated risk of depression and diabetes but no large-scale study has characterized their relationship. We aimed to assess this association and to evaluate possible explanatory factors.

Methods

Analysis of cross-sectional data from a national sample of 1155 people with psychosis who gave a fasting blood sample and could be tested for diabetes mellitus. The association between current diabetes mellitus and current depression was estimated using logistic regression, adjusted for age, sex and current psychotropic medication.

Results

A diagnosis of depression was significantly associated with diabetes (OR = 2.16, P = .048) and diabetes medication (OR = 2.50, P = .050) in people with schizophrenia but no other psychosis subtype. Adjustment for cognitive processing speed and current residence (especially psychiatric hospitalization) attenuated that association to nonsignificance. Diabetes and diabetes medication were not significantly associated with antidepressant or mood stabilizer medication.

Conclusions

Clinicians should be aware that people with schizophrenia and diabetes have twice the rate of current depression, and that comorbid diabetes and depression is associated with cognitive impairment and hospitalization. Efforts to disentangle the causal pathways between diabetes, depression, and cognition in people with schizophrenia may be complicated by multiple indications in people with psychosis for the prescription of depression medication, and their lack of association with diabetes mellitus.

C-reactive protein and cardiovascular risk in bipolar disorder patients: A systematic review

OBJECTIVES

New research is revealing a strong association between inflammatory markers with bipolar disorder (BD), potentially due to the high prevalence of cardiovascular disease and cardiovascular risk factors in BD. We aimed to synthesize the literature examining the association between the clinically most relevant inflammatory marker, C-reactive protein (CRP) and cardiovascular disease and cardiovascular risk factors in patients with BD.

METHODS

MEDLINE, Embase and PsychInfo were systematically searched for all relevant English language articles published prior to April 2017. Articles were included if they examined the association between CRP and cardiovascular risk factors/disease in BD.

RESULTS

Fifteen relevant articles were retrieved. Studies were mostly cross-sectional and heterogeneous in the cardiovascular risk factors investigated. Overall, elevated CRP was associated with increased risk of metabolic syndrome, elevated body mass index, higher waist circumference, and obesity. CRP was inconsistently associated with elevated fasting glucose, insulin levels, serum triglycerides, total cholesterol levels, and low high density lipoprotein (HDL) levels. Atypical antipsychotic use may mediate some of these effects. No study examined CRP's association with actual cardiovascular disease (e.g. coronary artery disease) in BD.

CONCLUSIONS

In BD, CRP is associated with increases in several cardiovascular risk factors, suggesting that systemic inflammation could be a shared driving force for both outcomes of BD and cardiovascular risk. Further longitudinal research is needed in this area to verify causality, including an examination of actual cardiovascular disease. Non-pharmacological and pharmacological treatments with anti-inflammatory effects should also be investigated, particularly in patients with increased CRP, for their potential to reduce cardiovascular risk in BD.

Bipolar disorder and diabetes mellitus: evidence for disease-modifying effects and treatment implications

BACKGROUND

Bipolar disorder refers to a group of chronic psychiatric disorders of mood and energy levels. While dramatic psychiatric symptoms dominate the acute phase of the diseases, the chronic course is often determined by an increasing burden of co-occurring medical conditions. High rates of diabetes mellitus in patients with bipolar disorder are particularly striking, yet unexplained. Treatment and lifestyle factors could play a significant role, and some studies also suggest shared pathophysiology and risk factors.

OBJECTIVE

In this systematic literature review, we explored data around the relationship between bipolar disorder and diabetes mellitus in recently published population-based cohort studies with special focus on the elderly.

METHODS

A systematic search in the PubMed database for the combined terms "bipolar disorder" AND "elderly" AND "diabetes" in papers published between January 2009 and December 2015 revealed 117 publications; 7 studies were large cohort studies, and therefore, were included in our review.

RESULTS

We found that age- and gender- adjusted risk for diabetes mellitus was increased in patients with bipolar disorder and vice versa (odds ratio range between 1.7 and 3.2).

DISCUSSION

Our results in large population-based cohort studies are consistent with the results of smaller studies and chart reviews. Even though it is likely that heterogeneous risk factors may play a role in diabetes mellitus and in bipolar disorder, growing evidence from cell culture experiments and animal studies suggests shared disease mechanisms. Furthermore, disease-modifying effects of bipolar disorder and diabetes mellitus on each other appear to be substantial, impacting both treatment response and outcomes.

CONCLUSIONS

The risk of diabetes mellitus in patients with bipolar disorder is increased. Our findings add to the growing literature on this topic. Increasing evidence for shared disease mechanisms suggests new disease models that could explain the results of our study. A better understanding of the complex relationship between bipolar disorder and diabetes mellitus could lead to novel therapeutic approaches and improved outcomes.

A differential impact of lithium on endothelium-dependent but not on endothelium-independent vessel relaxation

Lithium is drug for bipolar disorders with a narrow therapeutic window. Lithium was recently reported to prevent stroke and protect vascular endothelium but tends to accumulate particularly in the brain and kidney. Here, adverse effects are common; however mechanisms are still vaguely understood. If lithium could also negatively influence the endothelium is unclear. We hypothesize that at higher lithium levels, the effects on endothelium reverses--that lithium also impairs endothelial-dependent relaxation of blood vessels. Vessel grafts from de-nerved murine aortas and porcine middle cerebral arteries were preconditioned using media supplemented with lithium chloride or acetate (0.4-100 mmol/L). Native or following phenylephrine-induced vasoconstriction, the relaxation capacity of preconditioned vessels was assessed by isometric myography, using acetylcholine to test the endothelium-dependent or sodium nitroprusside to test the endothelium-independent vasorelaxation, respectively. At the 0.4 mmol/L lithium concentration, acetylcholine-induced endothelium-dependent vessel relaxation was slightly increased, however, diminished in a concentration-dependent manner in vessel grafts preconditioned with lithium at higher therapeutic and supratherapeutic concentrations (0.8-100 mmol/L). In contrast, endothelium-independent vasorelaxation remained unaltered in preconditioned vessel grafts at any lithium concentration tested. Lithium elicits opposing effects on endothelial functions representing a differential impact on the endothelium within the narrow therapeutic window. Lithium accumulation or overdose reduces endothelium-dependent but not endothelium-independent vasorelaxation. The differentially modified endothelium-dependent vascular response represents an additional mechanism contributing to therapeutic or adverse effects of lithium.

Medical comorbidity, acute medical care use in late-life bipolar disorder: a comparison of lithium, valproate, and other pharmacotherapies

OBJECTIVE

Bipolar disorder is associated with high rates of medical comorbidity, particularly in late life. Little is known about medical health service utilization and potential effects of bipolar pharmacotherapy. We hypothesized that lithium use would not be associated with higher rates of medical hospitalization.

METHODS

Population-based retrospective cohort study of 1388 bipolar disorder patients aged ≥66years discharged from a psychiatric hospitalization in Ontario, Canada, between 2006 and 2012. Patients were divided into lithium users, valproate users, and non-lithium/non-valproate users. The main outcome was acute non-psychiatric, medical/surgical hospitalization during 1-year follow-up.

RESULTS

The rate of medical hospitalizations was 0.22 per patient-year. Time-to-medical hospitalization did not differ among lithium, valproate, and non-lithium/non-valproate users after adjusting for age, sex, past medical hospitalization, and antipsychotic use. Lithium, valproate, and non-lithium/non-valproate users did not differ markedly in terms of reason for medical hospitalization, 1-year acute medical health utilization outcomes, and medical comorbidity rates.

CONCLUSION

There were high rates of health service use for medical conditions among older adults with bipolar disorder, but this did not appear to be associated with lithium use, compared to valproate and other medication use (e.g., antipsychotics). A proactive collaborative care approach may prevent medical service utilization in severe late-life bipolar disorder.

Diabetes mellitus onset in geriatric patients: does long-term atypical antipsychotic exposure increase risk?

BACKGROUND

Diabetes mellitus (DM) in common in adults using psychotropic medications. However, it remains largely unknown whether there is an additional risk of diabetes mellitus (DM) in elderly psychiatric outpatients, particularly those with long-term exposure to atypical antipsychotics (AP).

METHODS

In this retrospective longitudinal study, 61 atypical AP-exposed and 64 atypical AP-unexposed geriatric psychiatric patients were compared to a group of 200 psychotropic-naïve controls. Our main composite outcome was diabetes incidence over a 4-year period, defined by fasting blood glucose ≥ 7.0 mmol/L or a new-onset oral hypoglycaemic or insulin prescription during the 4-year period.

RESULTS

The 4-year incidence of DM did not differ significantly between groups: 12.3%, 6.7%, and 11.9% in the atypical AP-exposed, atypical AP-unexposed, and control groups, respectively (χ(2) = 1.40, P = 0.50). Depression and antidepressant, cholinesterase inhibitor, and valproate use were independently associated with increases in fasting glucose. However, hyperglycaemia and hypoglycaemic prescriptions were not more common in geriatric psychiatric patients.

CONCLUSIONS

DM does not appear to be more common in geriatric psychiatric patients than similarly aged controls and is not more common in atypical AP users. However, depression and antidepressant, cholinesterase inhibitor, and valproate use may increase fasting glucose levels, and the clinical significance of this warrants further investigation. Nonetheless, given the rates of untreated and undertreated fasting hyperglycaemia in both our geriatric psychiatric and control samples (>10% of all patients), we recommend regular screening for DM in these populations.

Common biological mechanisms between bipolar disorder and type 2 diabetes: Focus on inflammation

INTRODUCTION

Bipolar disorder (BD) patients present a 3-5 fold greater risk of developing type 2 diabetes (T2D) compared to general population. The underlying mechanisms for the increased prevalence of T2D in BD population are poorly understood.

OBJECTIVES

The purpose of this review is to critically review evidence suggesting that inflammation may have an important role in the development of both BD and T2D.

RESULTS

The literature covered in this review suggests that inflammatory dysregulation take place among many BD patients. Such dysregulated and low grade chronic inflammatory process may also increase the prevalence of T2D in BD population. Current evidence supports the hypothesis of dysregulated inflammatory processes as a critical upstream event in BD as well as in T2D.

CONCLUSIONS

Inflammation may be a factor for the development of T2D in BD population. The identification of inflammatory markers common to these two medical conditions will enable researchers and clinicians to better understand the etiology of BD and develop treatments that simultaneously target all aspects of this multi-system condition.