Increased risk of developing stroke among patients with bipolar disorder after an acute mood episode: a six-year follow-up study

International Trends in Lithium Use for Pharmacotherapy and Clinical Correlates in Bipolar Disorder: A Scoping Review

Lithium remains an effective option in the treatment of bipolar disorder (BD). Thus, we aim to characterize the pharmaco-epidemiological patterns of lithium use internationally over time and elucidate clinical correlates associated with BD using a scoping review, which was conducted using the methodological framework by Arksey and O'Malley (2005). We searched several databases for studies that examined the prescriptions for lithium and clinical associations in BD from inception until December 2023. This review included 55 articles from 1967 to 2023, which collected data from North America (n = 24, 43.6%), Europe (n = 20, 36.4%), and Asia (n = 11, 20.0%). The overall prescription rates ranged from 3.3% to 84% (33.4% before and 30.6% after the median year cutoffs). Over time, there was a decline in lithium use in North America (27.7% before 2010 to 17.1% after 2010) and Europe (36.7% before 2003 to 35.7% after 2003), and a mild increase in Asia (25.0% before 2003 to 26.2% after 2003). Lithium use was associated with specific demographic (e.g., age, male gender) and clinical factors (e.g., lower suicide risk). Overall, we found a trend of declining lithium use internationally, particularly in the West. Specific clinical correlates can support clinical decision-making for continued lithium use.

Impact of Preexisting Alcohol Use Disorder, Bipolar Disorder, and Schizophrenia on Ischemic Stroke Risk and Severity: A Lebanese Case-Control Study

BACKGROUND

Stroke remains a major leading cause of morbidity and death globally. For ischemic stroke, the most frequent type of stroke, there are numerous risk models and risk assessments offered. Further research into potential risk factors or triggers is being sought to improve stroke risk models. Schizophrenia, bipolar disorder, and alcohol use disorder are all common causes of serious mental illnesses in the general population. Due to the tangled relationship between stroke and many chronic illnesses, lifestyle factors, and diet that may be present in a patient with a mental disease, the relationship between mental diseases and stroke requires further validation. Consequently, the purpose of this study is to assess the potential influence of bipolar disorder, schizophrenia, and alcohol use disorder on stroke patients as compared to non-stroke participants, after controlling for demographic, physical, and medical conditions. We aimed, as a secondary objective, to evaluate the impact of these pre-existing disorders on stroke severity levels.

METHODS

This research is a case-control survey study involving 113 Lebanese patients with a clinical diagnosis of ischemic stroke and 451 gender-matched volunteers without clinical signs of stroke as controls recruited from several hospitals in Lebanon (April 2020-April 2021). Based on the participant's consent, data was collected by filling out an anonymous paper-based questionnaire.

RESULTS

All of the odds ratios (ORs) generated by our regression model were greater than 1, indicating that the factors studied were associated with an increased risk of ischemic stroke. As such having schizophrenia (adjusted OR [aOR]: 6.162, 95% confidence interval [CI]: 1.136-33.423), bipolar disorder (aOR: 4.653, 95% CI: 1.214-17.834), alcohol use disorder (aOR: 3.918, 95% CI: 1.584-9.689), atrial fibrillation (aOR: 2.415, 95% CI: 1.235-4.721), diabetes (aOR: 1.865, 95% CI: 1.117-3.115), heart diseases (aOR: 9.890, 95% CI: 5.099-19.184), and asthma-COPD (aOR: 1.971, 95% CI: 1.190-3.263) were all involved with a high risk of developing an ischemic stroke. Moreover, obesity (aOR: 1.732, 95% CI: 1.049-2.861) and vigorous physical activity (aOR: 4.614, 95% CI: 2.669-7.978) were also linked to an increased risk of stroke. Moreover, our multinomial regression model revealed that the odds of moderate to severe/severe stroke were significantly higher in people with pre-stroke alcohol use disorder (aOR: 1.719, 95% CI: 1.385-2.133), bipolar disorder (aOR: 1.656, 95% CI: 1.281-2.141), and schizophrenia (aOR: 6.884, 95% CI: 3.294-11.492) compared to people who had never had a stroke.

CONCLUSION

The findings in our study suggest that individuals with schizophrenia, bipolar disorder, and alcohol use disorder may be at a higher risk for ischemic stroke and exhibit more severe symptoms. We believe that the first step toward creating beneficial preventative and treatment interventions is determining individuals with schizophrenia, bipolar disorder, or alcohol use disorder, assessing their risk of ischemic stroke, developing more integrated treatments, and closely monitoring the long-term outcome in the event of an ischemic stroke.

Machine learning algorithms revealed distorted retinal vascular branching in individuals with bipolar disorder

BACKGROUND

Converging evidence designate vascular vulnerability in bipolar disorder. The predisposition progresses into distortion in time, thus detection of the vascular susceptibility may help reducing morbidity and mortality. It was aimed to assess retinal fundus vasculature in cardiovascular risk-free patients with bipolar disorder.

METHODS

Total of 68 individuals (38 patients with bipolar disorder, 30 healthy controls) were enrolled. In order to avoid from degenerative processes, participants were between 18 and 45 years of age, vascular risk factors were eliminated. Microscopic retinal fundus images were processed with machine learning algorithms (multilayer perceptron and support vector machine) and artificial neural network approaches.

RESULTS

In comparison to the healthy control group, the bipolar disorder group had lower number of breaking points (P < 0.001), lower number of curved vessel segments (P < 0.001). Total length of smooth vessels was longer (P = 0.040), and total length of curved vessel segments was significantly shorter (P < 0.001) than the control group. Vascular endothelial growth factor levels and gender were the confounders. There were significant correlations between vascular measures and serum lipid levels.

LIMITATIONS

Sample size was small and patients were on various medications.

CONCLUSIONS

These results indicate distortion in retinal vascular branching in bipolar disorder. Disrupted branching may reflect disturbed prosperity of retinal vascular plexus in patients with bipolar disorder. Alterations in the retinal vessels might be indicators of disruption in cerebral vascular system efficiency and thus neurovascular unit dysfunction in bipolar disorder.

Association of Bipolar Disorder With Major Adverse Cardiovascular Events: A Population-Based Historical Cohort Study

OBJECTIVE

This study aimed to assess the association of bipolar disorder (BD) with risk of major adverse cardiac events (MACEs) after adjusting for established cardiovascular disease (CVD) risk factors.

METHODS

We conducted a population-based historical cohort study using the Rochester Epidemiology Project. Patients older than 30 years with a clinical encounter from 1998 to 2000 with no prior MACE, atrial fibrillation, or heart failure were followed up through March 1, 2016. BD diagnosis was validated by chart review. Cox proportional hazards regression models were adjusted for established CVD risk factors, alcohol use disorder, other substance use disorders (SUDs), and major depressive disorder (MDD).

RESULTS

The cohort included 288 individuals with BD (0.81%) and 35,326 individuals without BD as the reference group (Ref). Median (interquartile range) follow-up was 16.5 (14.6-17.5) years. A total of 5636 MACE events occurred (BD, 59; Ref, 5577). Survival analysis showed an association between BD and MACE (median event-free-survival rates: BD, 0.80; Ref, 0.86; log-rank p = .018). Multivariate regression adjusting for age and sex also yielded an association between BD and MACE (hazard ratio [HR] = 1.93; 95% confidence interval [CI] = 1.43-2.52; p < .001). The association remained significant after further adjusting for smoking, diabetes mellitus, hypertension, high-density lipoprotein cholesterol, and body mass index (HR = 1.66; 95% CI = 1.17-2.28; p = .006), and for alcohol use disorder, SUD, and MDD (HR = 1.56; 95% CI = 1.09-2.14; p = .010).

CONCLUSIONS

In this study, BD was associated with an increased risk of MACE, which persisted after adjusting for established CVD risk factors, SUDs, and MDD. These results suggest that BD is an independent risk factor for major clinical cardiac disease outcomes.

Association of total pre-existing comorbidities with stroke risk: a large-scale community-based cohort study from China

Background

Comorbidities, any other coexisting diseases in patients with a particular index disease, are known to increase the mortality of a stroke. However, the association of pre-existing comorbidities with stroke risk has not been fully studied.

Methods

This study included 16,246 adults from a prospective community-based cohort with a baseline survey conducted in 2013 in China. Participants were followed up with hospitalization records and the Cause of Death Registry. The association of eight pre-existing comorbidities (coronary heart disease, hyperlipidemia, hypertension, diabetes, previous stroke, chronic obstructive pulmonary disease, nephropathy, and cancer) with stroke risk was analyzed using the Cox proportional hazard model in 2020.

Results

At a median follow-up of 5.5 years, a total of 449 participants (206 men and 243 women) developed a stroke. Four pre-existing comorbidities (hypertension, congenital heart disease, previous stroke, and diabetes) were independently and positively associated with the risk for all types of stroke. The adjusted hazard ratios for participants with only 1 and ≥ 2 pre-existing comorbidities compared with those without pre-existing conditions were 1.96 (95% CI: 1.44, 2.67; P < 0.001) and 2.87 (95% CI; 2.09, 3.94; P < 0.001) for total stroke, respectively. Moreover, male and female participants with a combination of increased age and a higher number of pre-existing comorbidities experienced the greatest risk of stroke.

Conclusions

The number of pre-existing comorbidities was independently associated with an increased risk of stroke. There was a synergic effect between increased age and a higher number of pre-existing comorbidities on stroke occurrence. Our novel findings emphasize the importance and potential application of pre-existing comorbidities as a risk indicator in stroke prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12002-1.

Bipolar disorder and the risk for stroke incidence and mortality: a meta-analysis

OBJECTIVE

Bipolar disorder (BD) may be associated with an increased risk of stroke, but to date, the results of the studies are still controversial. This study aimed to assess the association of BD with stroke incidence and mortality by a meta-analysis.

METHOD

PubMed, EMBASE, the Cochrane library databases, and Web of Science databases were searched from inception to July 2020. We regarded stroke as a composite endpoint. The pooled hazard ratio (HRs) of 95% confidence interval (Cls) was calculated. Subgroup and sensitivity analyses were performed to assess the potential sources of heterogeneity of the pooled estimation.

RESULTS

A total of 7 studies involving a total of 13,305,007 participants were included in this meta-analysis. Pooled analysis showed participants with BD experienced a significantly increased risk of both stroke incidence (combined HR, 1.43; 95% CI, 1.24-1.66; p = 0.000) and stroke mortality (combined HR, 1.54; 95% CI, 1.09-2.18; p = 0.013) compared to participants without BD. In addition, the pooled estimate of multivariate HRs of stroke incidence and mortality were 1.35 (95% CI: 1.26-1.45); 2.30 ( 95% CI: 1.37-3.85) among men and 1.43 (95% CI:1.27-1.60); 2.08 (95% CI:1.60-2.71) among women respectively.

CONCLUSIONS

This meta-analysis suggests that BD may modestly increase the risk of both stroke incidence and mortality. Extensive clinical observational studies should be conducted in the future to explore whether BD is a potentially modifiable risk factor for stroke.

Post-traumatic stress disorder and its association with stroke and stroke risk factors: A literature review

Stroke is a major cause of mortality and disability globally that has multiple risk factors. A risk factor that has recently gained more attention is post-traumatic stress disorder (PTSD). Literature searches were carried out for updated PTSD information and for the relationship between PTSD and stroke. The review was divided into two sections, one exploring PTSD as an independent risk factor for stroke, with a second concentrating on PTSD's influence on stroke risk factors. The study presents accumulating evidence that shows traumatic stress predicts stroke and is also linked to many major stroke risk factors. The review contributes knowledge to stroke aetiology and acts as a reference for understanding the relationship between PTSD and stroke. The information presented indicates that screening and identification of traumatic experience would be beneficial for directing stroke patients to appropriate psychological and lifestyle interventions. In doing so, the burden of stroke may be reduced worldwide.

Elderly Bipolar Disorder

PURPOSE OF REVIEW

With more individuals reaching older ages, bipolar disorder is no longer a rare illness in the elderly. Despite the growing number of the older individuals with the illness, there are few studies that focus on bipolar disorder in the geriatric population leading to gaps in clinical knowledge and treatment. The aim of this study is therefore to increase understanding by summarizing the available literature on the epidemiology, symptomatology, comorbidities, and treatment recommendations in this cohort, as well as to suggest areas for future clinical and research focus.

RECENT FINDINGS

The prevalence of bipolar disorder is underestimated in the geriatric population. The illness maintains the main features observed in the other cohorts but it also has some specific characteristics in the older individuals. In this cohort, psychiatric and medical comorbidities tend to be the rule rather than the exception. Higher rates of cognitive impairments than age- and education-matched groups present across all of the illness phases. Treatment is more challenging in the elderly individuals due to higher rates of comorbidities and susceptibility to medication side effects. Two cohorts of older individuals with bipolar disorder can be recognized, those with symptoms that start earlier in life and those with late-life onset. Although the knowledge about elderly bipolar disorder is only slowly growing, it is increasingly recognized as an illness with unique features. More work is needed to improve diagnosis and to establish treatment guidelines.

Call to action regarding the vascular-bipolar link: A report from the Vascular Task Force of the International Society for Bipolar Disorders

OBJECTIVES

The association of bipolar disorder with early and excessive cardiovascular disease was identified over a century ago. Nonetheless, the vascular-bipolar link remains underrecognized, particularly with regard to how this link can contribute to our understanding of pathogenesis and treatment.

METHODS

An international group of experts completed a selective review of the literature, distilling core themes, identifying limitations and gaps in the literature, and highlighting future directions to bridge these gaps.

RESULTS

The association between bipolar disorder and vascular disease is large in magnitude, consistent across studies, and independent of confounding variables where assessed. The vascular-bipolar link is multifactorial and is difficult to study given the latency between the onset of bipolar disorder, often in adolescence or early adulthood, and subsequent vascular disease, which usually occurs decades later. As a result, studies have often focused on risk factors for vascular disease or intermediate phenotypes, such as structural and functional vascular imaging measures. There is interest in identifying the most relevant mediators of this relationship, including lifestyle (eg, smoking, diet, exercise), medications, and systemic biological mediators (eg, inflammation). Nonetheless, there is a paucity of treatment studies that deliberately engage these mediators, and thus far no treatment studies have focused on engaging vascular imaging targets.

CONCLUSIONS

Further research focused on the vascular-bipolar link holds promise for gleaning insights regarding the underlying causes of bipolar disorder, identifying novel treatment approaches, and mitigating disparities in cardiovascular outcomes for people with bipolar disorder.

Cognitive impairment in late life bipolar disorder: Risk factors and clinical outcomes

BACKGROUND

Late Life Bipolar Disorder (LLBD) is associated with a high prevalence of cognitive impairments, but few studies have examined their risk factors and clinical correlates METHODS: Participants with bipolar disorder older than 60 (n = 86) were recruited from psychiatric outpatient and inpatients units. Patients were assessed with various instruments, including the Clinical Dementia Rating scale, the Montreal Cognitive Assessment and the Cumulative Illness Rating Scale. The distribution of disorder-specific and general risk factors was compared between patients with LLBD plus cognitive impairments (mild cognitive impairment or dementia) and those with LLBD but no cognitive impairment. Analyses were first conducted at the bivariate level, then using multiple regression. The association with disability, aggressive behavior and suicidal ideation was also explored.

RESULTS

Cognitive impairments in LLBD were associated with a diagnosis of type 1 bipolar disorder (OR = 6.40, 95%CI: 1.84 - 22.31, p = 0.004), fewer years of education (OR = 0.79, 95%CI: 0.69 - 0.91, p = 0.001) and higher severity of physical diseases (OR 26.54, 95%CI: 2.07 - 340.37, p = 0.01). Moreover, cognitive impairments were associated with an increased likelihood of disability and recent aggressive behavior, but not suicidal ideation.

LIMITATIONS

retrospective design, conflation of MCI and dementia, not all subjects were in euthymia CONCLUSIONS: In LLBD, the presence of cognitive impairments was associated with a diagnosis of type I bipolar disorder, lower education and more severe physical comorbidities. In turn, MCI or dementia were associated with increased disability and aggressive behavior. These findings may aid the identification of patients at risk for cognitive deterioration in everyday clinical practice.

A review of psychosocial factors and stroke: A new public health problem

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted.

METHODS

Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified.

RESULTS

Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women.

CONCLUSION

This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Adverse stroke outcomes among patients with bipolar disorder

Failure to deliver the standard stroke care is suspected to be a potential reason for disproportionately high mortality among patients with co-morbid bipolar disorder (BD). Few studies have explored adverse outcomes and medical care costs concurrently (as a proxy for care intensity) among patients with BD admitted for stroke. Data for this nationwide population-based study were extracted from the Taiwan National Health Insurance Research Database, on 580 patients with BD hospitalized for stroke (the study group) and a comparison group consisting of randomly selected 1740 stroke patients without BD matched by propensity scores. Conditional logistic regression was used to estimate odds ratios (OR) for adverse in-hospital outcomes between study group and comparison group. We found that stroke patients with BD had significantly lower in-hospital mortality (3.28% vs. 5.63%), acute respiratory failure (2.59% vs. 5.57%), and use of mechanical ventilation (6.55% vs. 10.23%) than the comparison group. After adjusting for geographical location, urbanization level, monthly income, hypertension, diabetes, hyperlipidemia, and coronary heart disease, the odds of in-hospital mortality, acute respiratory failure, and use of mechanical ventilation in the BD group were 0.56 (95% CI: 0.34–0.92), 0.46 (95% CI: 0.26–0.80), and 0.63 (95% CI: 0.44–0.91), respectively. No differences were found in hospitalization costs and the length of hospital stay. With comparable hospitalization costs and length of hospital stay, we concluded that stroke patients with BD had lower in-hospital mortality and serious adverse events compared to stroke patients without BD.

Reduced cerebrovascular reactivity among adolescents with bipolar disorder

OBJECTIVES

Cardiovascular disease (CVD) is excessive and premature among individuals with bipolar disorder (BD). Cerebrovascular reactivity (CVR), reflecting vasodilatory capacity of cerebral blood vessels in response to vasoactive substances, is a marker of cerebrovascular health. Despite informative findings in other diseases, CVR has not previously been examined in BD.

METHODS

Twenty-five adolescents with BD and 25 age and sex-matched psychiatrically healthy controls (HCs) completed six 15-second breath-holds (BHs) during functional magnetic resonance imaging (fMRI) at 3-Tesla. CVR was determined by comparing blood-oxygenation-level dependent (BOLD) signal changes. Voxel-wise contrasts were analyzed. Body mass index (BMI) was examined as a potential confound.

RESULTS

CVR in the posterior cingulate gyrus and periventricular white matter was lower in BD vs HC. After controlling for differences in BMI, additional between-group CVR differences were observed in the temporal poles, supramarginal gyrus, and lingual gyrus. There were no regions in which CVR was significantly greater in BD vs HC. CVR was not associated with mood symptoms.

CONCLUSIONS

This preliminary study provides evidence of cerebrovascular dysfunction in BD, including regions known to be susceptible to cerebrovascular dysfunction and/or disease. These findings warrant additional research on the causes and consequences of cerebrovascular dysfunction in early-onset BD.

Atopic diseases/diathesis and subsequent ischemic stroke among patients with bipolar disorder: A nationwide longitudinal study

INTRODUCTION

Previous studies have suggested that both bipolar disorder and atopy are associated with an increased risk of stroke. However, the role of atopic diseases/diathesis in the risk of stroke among patients with bipolar disorder remains unclear.

METHODS

Using Taiwan's National Health Insurance Research Database, we selected 55,593 patients with bipolar disorder between 2002 and 2008, divided them into patients with atopic diseases/diathesis (n = 21,050) and patients without atopic diseases/diathesis (n = 34,543), and observed them until the end of 2011. Patients who experienced a stroke during the follow-up period were identified.

RESULTS

Patients with bipolar disorder and atopic diseases/diathesis had an elevated risk of ischemic stroke (hazard ratio [HR]: 1.44, 95% confidence interval [CI]: 1.25-1.59) compared with patients with only bipolar disorder; a dose-dependent relationship was observed between the number of allergic comorbidities and the risk of ischemic stroke (1 atopic disease, HR: 1.30, 95% CI: 1.13-1.49; 2 atopic diseases, HR: 1.59, 95% CI: 1.33-1.91; ≥ 3 atopic diseases, HR: 2.09, 95% CI: 1.50-2.91).The role of atopic diseases in the risk of hemorrhagic stroke among patients with bipolar disorder was nonsignificant (HR: 0.84, 95% CI: 0.64-1.09).

CONCLUSIONS

Patients with bipolar disorder and atopic diseases/diathesis are more prone to ischemic stroke later in life than are those without atopic diseases/diathesis. Further study is required to investigate the underlying mechanism linking atopy, bipolar disorder, and stroke.

Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls

People with severe mental illness (SMI) - schizophrenia, bipolar disorder and major depressive disorder - appear at risk for cardiovascular disease (CVD), but a comprehensive meta-analysis is lacking. We conducted a large-scale meta-analysis assessing the prevalence and incidence of CVD; coronary heart disease; stroke, transient ischemic attack or cerebrovascular disease; congestive heart failure; peripheral vascular disease; and CVD-related death in SMI patients (N=3,211,768) versus controls (N=113,383,368) (92 studies). The pooled CVD prevalence in SMI patients (mean age 50 years) was 9.9% (95% CI: 7.4-13.3). Adjusting for a median of seven confounders, patients had significantly higher odds of CVD versus controls in cross-sectional studies (odds ratio, OR=1.53, 95% CI: 1.27-1.83; 11 studies), and higher odds of coronary heart disease (OR=1.51, 95% CI: 1.47-1.55) and cerebrovascular disease (OR=1.42, 95% CI: 1.21-1.66). People with major depressive disorder were at increased risk for coronary heart disease, while those with schizophrenia were at increased risk for coronary heart disease, cerebrovascular disease and congestive heart failure. Cumulative CVD incidence in SMI patients was 3.6% (95% CI: 2.7-5.3) during a median follow-up of 8.4 years (range 1.8-30.0). Adjusting for a median of six confounders, SMI patients had significantly higher CVD incidence than controls in longitudinal studies (hazard ratio, HR=1.78, 95% CI: 1.60-1.98; 31 studies). The incidence was also higher for coronary heart disease (HR=1.54, 95% CI: 1.30-1.82), cerebrovascular disease (HR=1.64, 95% CI: 1.26-2.14), congestive heart failure (HR=2.10, 95% CI: 1.64-2.70), and CVD-related death (HR=1.85, 95% CI: 1.53-2.24). People with major depressive disorder, bipolar disorder and schizophrenia were all at increased risk of CVD-related death versus controls. CVD incidence increased with antipsychotic use (p=0.008), higher body mass index (p=0.008) and higher baseline CVD prevalence (p=0.03) in patients vs.

CONTROLS

Moreover, CVD prevalence (p=0.007), but not CVD incidence (p=0.21), increased in more recently conducted studies. This large-scale meta-analysis confirms that SMI patients have significantly increased risk of CVD and CVD-related mortality, and that elevated body mass index, antipsychotic use, and CVD screening and management require urgent clinical attention.

Long-term risk of myocardial infarction and stroke in bipolar I disorder: A population-based Cohort Study

OBJECTIVES

To estimate the risk of fatal and non-fatal myocardial infarction (MI) and stroke in patients with bipolar I disorder compared to people without bipolar I disorder.

METHOD

Utilizing a records-linkage system spanning 30 years (1966-1996), a population-based cohort of 334 subjects with bipolar I disorder and 334 age and sex-matched referents from Olmsted County, Minnesota, U.S. was identified. Longitudinal follow-up continued until incident MI or stroke (confirmed by board-certified cardiologist/neurologist), death, or study end date (December 31, 2013). Cox proportional hazards models assessed the hazard ratio (HR) for MI or stroke, adjusting for potential confounders.

RESULTS

There was an increased risk of fatal or non-fatal MI or stroke (as a composite outcome) in patients with bipolar I disorder [HR 1.54, 95% confidence interval (CI) 1.02, 2.33; p=0.04]. However, after adjusting for baseline cardiovascular risk factors (alcoholism, hypertension, diabetes, and smoking), the risk was no longer significantly increased (HR 1.19, 95% CI 0.76, 1.86; p=0.46).

LIMITATIONS

Small sample size for the study design. Findings were not retained after adjustment for cardiovascular disease risk factors. Psychotropic medication use during the follow-up was not ascertained and was not included in the analyses.

CONCLUSION

This study in a geographically defined region in the U.S. demonstrated a significant increased risk of MI or stroke in bipolar I disorder, which was no longer significant after adjustment for cardiovascular risk factors.

Mania

PURPOSE OF REVIEW

Primary mania and hypomania in full or subsyndromal forms are the defining features of bipolar disorder and are common in neurologic patients, as are manic syndromes precipitated by medications used to treat neurologic disorders. This article addresses the diagnosis, pathophysiology, treatment, and course of bipolar disorder after a manic episode as well as mania as a manifestation of neurologic disease.

RECENT FINDINGS

Mania can be a primary psychiatric disorder but can also be a symptom of a neurologic disorder, especially right-sided cerebrovascular disease. Treatments (such as corticosteroids and dopaminergic agents) for neurologic illnesses regularly induce mania. The neurobiology of primary mania and bipolar disorder involves alterations in intracellular signaling, changes in gene expression, neural network interactions, and apoptosis. Except when induced by time-limited treatment with a provoking agent, mania tends to be highly recurrent and to alternate or be exhibited alongside depression. Symptoms of mania become more complex and treatment refractory with time, although effective treatment improves the long-term outcome.

SUMMARY

Behavioral manifestations of mania may be more obvious than affective symptoms, especially in patients with aprosodia. Atypical antipsychotic drugs are often first-line acute treatments, but the evidence supporting their long-term prophylactic efficacy is questionable. In addition to being an established mood stabilizer, lithium has putative neuroprotective properties, although a side effect can be impaired memory.

A reduced risk of stroke with lithium exposure in bipolar disorder: a population-based retrospective cohort study

OBJECTIVES

The risk of stroke is increased in patients with bipolar disorder. Lithium exhibits neuroprotective effects but the association between lithium use and the risk of stroke is unknown.

METHODS

A population-based retrospective cohort study was conducted by utilizing the National Health Insurance Research Database in Taiwan. Subjects who had first been diagnosed with bipolar disorder between 2001 and 2006 were identified. A propensity score (PS) for receiving lithium was calculated with variables of age, gender, and comorbidities. The patients with bipolar disorder receiving lithium within the period from diagnosis through to December 2011 were designated as the lithium group (n = 635). A 1:2 ratio was used to select PS-matched subjects with bipolar disorder without lithium use (n = 1,250). Multivariate Cox proportional hazards regression models were used to explore the association, rather than causal inference, of lithium exposure and the risk of stroke.

RESULTS

Of the 1,885 subjects, 86 (4.6%) experienced stroke, including 2.8% of the lithium group and 5.4% of the non-lithium group. Lithium use was associated with a significantly reduced risk of stroke [hazard ratio (HR) = 0.39, 95% confidence interval (CI): 0.22-0.68]. Reduced risks of stroke were also associated with the highest cumulative lithium dose [≥720 defined daily dose (DDD), HR = 0.25, 95% CI: 0.10-0.59], the longest cumulative exposure period (≥720 days, HR = 0.20, 95% CI: 0.06-0.64), and the highest exposure rate (≥2 DDD/day, HR = 0.39, 95% CI: 0.21-0.70).

CONCLUSIONS

Lithium use was significantly related to a reduced risk of stroke in patients with bipolar disorder.

Ischemic Stroke in Young Adults and Preexisting Psychiatric Disorders: A Nationwide Case-Control Study

Previous studies showed that psychiatric disorders such as major depression, bipolar disorders, and alcohol misuse are associated with an increased risk of ischemic stroke. However, the link between psychiatric disorders and stroke in the young population is rarely investigated. Using the Taiwan National Health Insurance Research Database, 2063 young adults aged between 18 and 45 years with ischemic stroke and 8252 age- and sex-matched controls were enrolled in our study between 1998 and 2011. Participants who had preexisting psychiatric disorders were identified. After adjusting for preexisting physical disorders and demographic data, patients with ischemic stroke had an increased risk of having preexisting psychiatric disorders, including bipolar disorder (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.06∼4.67), unipolar depression (OR: 2.15, 95% CI: 1.62∼2.86), anxiety disorders (OR: 2.63, 95% CI: 1.87∼3.69), and alcohol use disorders (OR: 2.86, 95% CI: 1.79∼4.57). Young ischemic stroke (age ≥30 years) was related to the risk of preexisting unipolar depression (OR: 1.49, 95% CI: 1.05∼2.11), anxiety disorders (OR: 1.99, 95% CI: 1.33∼2.97), and alcohol use disorders (OR: 2.54, 95% CI: 1.55∼4.14); very young stroke (age <30 years) was only associated with the risk of preexisting unipolar depression (OR: 4.15, 95% CI: 1.47∼11.72). Patients who had experienced ischemic stroke at age younger than 45 years had a higher risk of having pre-existing bipolar disorder, unipolar depression, anxiety disorders, and alcohol use disorders than those who did not after adjusting for demographic data and stroke-related medical comorbidities.

Valproic acid increases NO production via the SH-PTP1-CDK5-eNOS-Ser(116) signaling cascade in endothelial cells and mice

Valproic acid (VPA) with its inhibitory activity of histone deacetylase has been used in the treatment of epilepsy and bipolar disorder associated with cerebrovascular dysfunction. Because nitric oxide (NO) produced by endothelial NO synthase (eNOS) plays a role in the maintenance of vascular function, NO is likely to mediate VPA׳s drug effect, but its effect on NO production remains controversial. We investigated whether and how VPA regulates NO production in bovine aortic endothelial cells (BAECs) and mice. VPA increased NO production in BAECs, which was accompanied by a decrease in phosphorylation of eNOS at serine 116 (eNOS-Ser(116)) and cyclin-dependent kinase 5 at tyrosine 15 (CDK5-Tyr(15)). Ectopic expression of p25, a CDK5 activator, restored the VPA-inhibited eNOS-Ser(116) phosphorylation. In silico analysis revealed that the CDK5-Tyr(15) residue might be a substrate for SH2 domain-containing protein tyrosine phosphatase 1 (SH-PTP1), and CDK5 actually interacted with SH-PTP1. VPA increased SH-PTP1 expression and its activity. Stibogluconate, a specific SH-PTP1 inhibitor, reversed the VPA-inhibited phosphorylation of CDK5-Tyr(15) and eNOS-Ser(116). Knockdown of SH-PTP1 using small interfering RNA also reversed all the observed effects of VPA. Finally, both serum NO level and acetylcholine-induced aortic relaxation increased in VPA-medicated male mice. These increases were accompanied by increased SH-PTP1 expression and decreased phosphorylation of CDK5-Tyr(15) and eNOS-Ser(116) in mouse aortas. In conclusion, VPA increases NO production by inhibiting the CDK5-Tyr(15)-eNOS-Ser(116) phosphorylation axis; this process is mediated by SH-PTP1. VPA may be useful in the treatment of NO-related cerebrocardiovascular diseases.

Risk of myocardial infarction and stroke in bipolar disorder: a systematic review and exploratory meta-analysis

OBJECTIVE

To review the evidence on and estimate the risk of myocardial infarction and stroke in bipolar disorder.

METHOD

A systematic search using MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and bibliographies (1946 - May, 2013) was conducted. Case-control and cohort studies of bipolar disorder patients age 15 or older with myocardial infarction or stroke as outcomes were included. Two independent reviewers extracted data and assessed quality. Estimates of effect were summarized using random-effects meta-analysis.

RESULTS

Five cohort studies including 13 115 911 participants (27 092 bipolar) were included. Due to the use of registers, different statistical methods, and inconsistent adjustment for confounders, there was significant methodological heterogeneity among studies. The exploratory meta-analysis yielded no evidence for a significant increase in the risk of myocardial infarction: [relative risk (RR): 1.09, 95% CI 0.96-1.24, P = 0.20; I(2)  = 6%]. While there was evidence of significant study heterogeneity, the risk of stroke in bipolar disorder was significantly increased (RR 1.74, 95% CI 1.29-2.35; P = 0.0003; I(2)  = 83%).

CONCLUSION

There may be a differential risk of myocardial infarction and stroke in patients with bipolar disorder. Confidence in these pooled estimates was limited by the small number of studies, significant heterogeneity and dissimilar methodological features.

Bipolar disorder after stroke in an elderly patient

The onset of bipolar disorder (BD) secondary to a stroke event is a rare clinical entity. Although it may be related to specific regions of the brain, several other factors have been linked to its expression such as subcortical atrophy or chronic vascular burden. While precise locations and cerebral circuits involved in the bipolarity expression after stroke still need to be determined, their investigation represents an opportunity to study brain function and BD etiopathogenesis. We present a BD secondary to multiple subcortical biparietal lacunar infarctions, a lacunar infarction in left putamen and an ischemic lesion at the cerebral trunk evolving the right median portion, in a 65-year-old male patient who experienced manic, hypomanic, and depressive episodes, after 6, 10, and 16 months, respectively, of the cerebrovascular events.

The incidence and relative risk of stroke among patients with bipolar disorder: a seven-year follow-up study

Objective

This study aimed to estimate the incidence and relative risk of stroke and post-stroke all-cause mortality among patients with bipolar disorder.

Methods

This study identified a study population from the National Health Insurance Research Database (NHIRD) between 1999 and 2003 that included 16,821 patients with bipolar disorder and 67,284 age- and sex-matched control participants without bipolar disorder. The participants who had experienced a stroke between 1999 and 2003 were excluded and were randomly selected from the NHIRD. The incidence of stroke (ICD-9-CM code 430–438) and patient survival after stroke were calculated for both groups using data from the NIHRD between 2004 and 2010. A Cox proportional-hazards model was used to compare the seven-year stroke-free survival rate and all-cause mortality rate across the two cohorts after adjusting for confounding risk factors.

Results

A total of 472 (2.81%) patients with bipolar disorder and 1,443 (2.14%) controls had strokes over seven years. Patients with bipolar disorder were 1.24 times more likely to have a stroke (95% CI = 1.12–1.38; p<0.0001) after adjusting for demographic characteristics and comorbid medical conditions. In addition, 513 (26.8%) patients who had a stroke died during the follow-up period. The all-cause mortality hazard ratio for patients with bipolar disorder was 1.28 (95% CI = 1.06–1.55; p = 0.012) after adjusting for patient, physician and hospital variables.

Conclusions

The likelihood of developing a stroke was greater among patients with bipolar disorder than controls, and the all-cause mortality rate was higher among patients with bipolar disorder than controls during a seven-year follow-up period.

Increased risk of ischemic stroke in cervical cancer patients: a nationwide population-based study

Background

Increased risk of ischemic stroke has been validated for several cancers, but limited study evaluated this risk in cervical cancer patients. Our study aimed to evaluate the risk of ischemic stroke in cervical cancer patients.

Methods

The study analyzed data from the 2003 to 2008 National Health Insurance Research Database (NHIRD) provided by the National Health Research Institutes in Taiwan. Totally, 893 cervical cancer patients after radiotherapy and 1786 appendectomy patients were eligible. The Kaplan-Meier method and the Cox proportional hazards model were used to assess the risk of ischemic stroke.

Results

The 5-year cumulative risk of ischemic stroke was significantly higher for the cervical cancer group than for the control group (7.8% vs 5.1%; p <0.005). The risk of stroke was higher in younger (age <51 years) than in older (age ≥51 years) cervical cancer patients (HR = 2.73, p = 0.04; HR = 1.37, p = 0.07) and in patients with more than two comorbid risk factors (5 years cumulative stroke rate of two comorbidities: 15% compared to no comorbidities: 4%).

Conclusions

These study demonstrated cervical cancer patients had a higher risk of ischemic stroke than the general population, especially in younger patients. Strategies to reduce this risk should be assessed.

Medical costs and vasculometabolic comorbidities among patients with bipolar disorder in Taiwan - a population-based and matched-control study

BACKGROUND

Bipolar disorder (BD) is a costly disease with a high rate of vasculometabolic comorbidities. The aims of this study were to explore the 1-year treatment cost, including total medical and non-psychiatric services, and the prevalence of vasculometabolic comorbidities in individuals with BD.

METHODS

A nationwide population-based dataset, covering the years 2006 and 2007, was obtained from the Taiwan National Health Insurance claims database. The study sample comprised patients discharged from hospitals between 1 January 2006 and 31 December 2007. Annual non-psychiatric and total medical costs and vasculometabolic comorbidities were examined. Generalized linear models were used to examine the medical costs, and conditional logistic regression analyses were carried out to test the prevalence of vasculometabolic comorbidities in people with BD and to compare this with that found in matched controls.

RESULTS

The total medical cost was 11-fold higher (New Taiwan [NT] $227,040 vs. NT$20,461), and the non-psychiatric medical cost was 1.7-fold higher (NT$33,173 vs. NT$19,406) with regard to the individuals with BD vs. the matched controls. The prevalence of vasculometabolic comorbidities was significantly higher in the individuals with BD than in the controls (ratio ranging from 1.86 to 4.06).

CONCLUSIONS

Both the non-psychiatric healthcare utilization and the prevalence of vasculometabolic comorbidities are higher with regard to individuals with BD vs. their matched controls. Therefore, treatment of BD should integrate medical and psychiatric care to decrease the impact of medical comorbidities, which may also decrease the overall medical cost.

The incidence of venous thromboembolism in cervical cancer: a nationwide population-based study

Background

Venous thromboembolism (VTE) is a life-threatening condition that occurs as a complication of cervical cancer. The aim of this study was to evaluate the incidence of VTE in cervical cancer patients during a 5-year follow-up.

Methods

The study analyzed data deposited between 2003 and 2008 in the National Health Insurance Research Database (NHIRD), provided by the National Health Research Institutes in Taiwan. Totally, 1013 cervical cancer patients after treatment and 2026 appendectomy patients were eligible. The Kaplan-Meier method and the Cox proportional hazards model were used to assess the VTE risk.

Results

The 5-year cumulative risk for VTE was significantly higher in the cervical cancer group than in the control group (3.3% vs 0.3%, p < 0.001). The hazard ratio for VTE was 10.14 times higher in the cervical cancer group than in the controls. The combined presence of more comorbidities was associated with a higher risk for VTE. Furthermore, cervical cancer patients without VTE had a significantly higher survival (75.3% vs 30.3%, p < 0.001).

Conclusions

The cumulative risk of VTE was significantly higher in cervical cancer patients, and these patients also had lower survival rates. Strategies to reduce these risks need to be examined.

Chronic kidney disease itself is a causal risk factor for stroke beyond traditional cardiovascular risk factors: a nationwide cohort study in Taiwan

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of mortality and morbidity in patients with chronic kidney disease (CKD). In Taiwan, CVD is dominated by strokes but there is no robust evidence for a causal relationship between CKD and stroke. This study aimed to explore such causal association.

METHODS

We conducted a nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database from 2004 to 2007. Each patient identified was individually tracked for a full three years from the index admission to identify those in whom any type of stroke developed. The study cohort consisted of patients hospitalized with a principal diagnosis of CKD and no traditional cardiovascular risk factors at baseline (n = 1393) and an age-matched control cohort of patients hospitalized for appendectomies (n = 1393, a surrogate for the general population). Cox proportional hazard regression and propensity score model were used to compare the three-year stroke-free survival rate of the two cohorts after adjustment for possible confounding factors.

RESULTS

There were 256 stroke patients, 156 (11.2%) in the study cohort and 100 (7.2%) in the control cohort. After adjusting for covariates, patients with primary CKD had a 1.94-fold greater risk for stroke (95% CI, 1.45-2.60; p<0.001) based on Cox regression and a 1.68-fold greater risk for stroke (95% CI, 1.25-2.25; p = 0.001) based on propensity score. This was still the case for two cohorts younger than 75 years old and without traditional cardiovascular risk factors.

CONCLUSIONS

This study of Taiwanese patients indicates that CKD itself is a causal risk factor for stroke beyond the traditional cardiovascular risk factors. Primary CKD patients have higher risk for stroke than the general population and all CKD patients, irrespective of the presence or severity of traditional cardiovascular risk factors, should be made aware of the stroke risk and monitored for stroke prevention.

The risk factors for elderly patients with bipolar disorder having cerebral infarction

OBJECTIVE

Patients with bipolar disorder are at high risk of developing strokes in the older life. Silent cerebral infarctions (SCIs) could be common in the elderly patients with bipolar disorder, but only small sample size reports are available. The purpose of this study was to assess the proportion of SCIs and determine the risk factors for cerebral infarction in elderly patients with bipolar disorder.

METHODS

We recruited 43 patients with bipolar disorder over the age of 60 to undergo whole-brain magnetic resonance imaging (MRI). We divided them into 2 groups depending on whether infarction was present, and compared the potential variables of these 2 groups.

RESULTS

There were 28 elderly patients with bipolar disorder (65.1%) having MRI-proven cerebral infarction. The SCIs were detected in 59.5% (N = 22) of 37 patients without a history of stroke, including 61.3% of 13 patients with late-onset age (>50 years) and 46.7% of 30 patients with typical-onset age (<50 years). Logistic regression revealed that comorbidity with metabolic diseases (95% confidence interval [CI] for odds ratio [OR] = 1.24-40.59) was most strongly associated with cerebral infarction. The leukocyte counts (95% CI for OR = 1.10-3.93) and fasting blood sugar (95% CI for OR = 1.00-1.07) during the most recent acute psychiatric admission may be substituted as the risk factors.

CONCLUSIONS

Cerebral infarctions tend to be neglected in more than half of the elderly patients with bipolar disorder, regardless of their age at onset. Metabolic abnormality and systemic inflammation may be the risk factors.

'It's a double edged sword': a qualitative analysis of the experiences of exercise amongst people with Bipolar Disorder

BACKGROUND

Little is known about the therapeutic or iatrogenic effects of exercise in individuals with Bipolar Disorder, despite its potential to benefit physical and mental health. Consequently the aim of the current study was to gather data on experiences of the relationship between exercise and Bipolar Disorder from people with personal experience of the condition. In particular we sought to determine the aspects of this relationship that are pertinent to Bipolar Disorder.

METHODS

Twenty five individuals with a diagnosis of Bipolar Disorder participated in a semi-structured interview concerning their views on the relationship between exercise and Bipolar Disorder. The data were subjected to qualitative analysis using an Interpretative Phenomenological Analysis approach.

RESULTS

Both a descriptive content analysis and a population-specific thematic analysis were conducted. The latter revealed three themes, all present in the majority of participants, which reflected key aspects of the relationship between Bipolar Disorder and exercise: regulating exercise for mood regulation, exercise as a double-edged sword, and bringing structure to chaos.

LIMITATIONS

Information on past and current treatment regimes was not collected, and additional lifestyle factors, such as diet and alcohol use, were not investigated. Interviews were conducted by telephone.

CONCLUSIONS

The data reveal a number of aspects of the relationship between exercise and Bipolar Disorder that require further investigation and that should be taken into account by clinicians or researchers designing exercise-based interventions for individuals with Bipolar Disorder.

Mental disorders as risk factors: assessing the evidence for the Global Burden of Disease Study

BACKGROUND

Mental disorders are associated with a considerable burden of disease as well as being risk factors for other health outcomes. The new Global Burden of Disease (GBD) Study will make estimates for both the disability and mortality directly associated with mental disorders, as well as the burden attributable to other health outcomes. Herein we discuss the process by which health outcomes in which mental disorders are risk factors are selected for inclusion in the GBD Study. We make suggestions for future research to strengthen the body of evidence for mental disorders as risk factors.

METHODS

We identified a list of potential associations between mental disorders and subsequent health outcomes based on a review of the literature and consultation with mental health experts. A two-stage filter was applied to identify mental disorders and health outcomes that meet the criteria for inclusion in the GBD Study. Major limitations in the current literature are discussed and illustrated with examples identified during our review.

RESULTS AND DISCUSSION

Only two associations are included in the new GBD Study. These associations are the increased risk of ischemic heart disease with major depression and mental disorders as a risk factor for suicide. There is evidence that mental disorders are independent risk factors for cardiovascular disease (CVD), type 2 diabetes and injuries. However, these associations were unable to be included because of insufficient data. The most common reasons for exclusion were inconsistent identification of 'cases', uncertain validity of health outcomes, lack of generalizability, insufficient control for confounding factors and lack of evidence for temporality.

CONCLUSIONS

CVD, type 2 diabetes and injury are important public health policy areas. Prospective community studies of outcomes in patients with mental disorders are required, and their design must address a range of confounding factors.

Mania and stroke: a systematic review

BACKGROUND

Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics.

METHODS

We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data.

RESULTS

From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%).

CONCLUSIONS

Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

Increased risk of ischemic stroke in young nasopharyngeal carcinoma patients

PURPOSE

Radiation/chemoradiotherapy-induced carotid stenosis and cerebrovascular events in patients with nasopharyngeal carcinoma (NPC) can cause severe disability and even death. This study aimed to estimate the risk of ischemic stroke in this patient population over more than 10 years of follow-up.

METHODS AND MATERIALS

The study cohorts consisted of all patients hospitalized with a principal diagnosis of NPC (n=1094), whereas patients hospitalized for an appendectomy during 1997 and 1998 (n=4376) acted as the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the stroke-free survival rate between the two cohorts after adjusting for possible confounding and risk factors.

RESULTS

Of the 292 patients with ischemic strokes, 62 (5.7%) were from the NPC cohort and 230 (5.3%) were from the control group. NPC patients ages 35-54 had a 1.66 times (95% CI, 1.16-2.86; p=0.009) higher risk of ischemic stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. There was no statistical difference in ischemic stroke risk between the NPC patients and appendectomy patients ages 55-64 years (hazard ratio=0.87; 95% CI, 0.56-1.33; p=0.524) after adjusting for other factors.

CONCLUSIONS

Young NPC patients carry a higher risk for ischemic stroke than the general population. Besides regular examinations of carotid duplex, different irradiation strategies or using new technique of radiotherapy, such as intensity modulated radiation therapy or volumetric modulated arc therapy, should be considered in young NPC patients.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

Lower mortality among stroke patients with schizophrenia: a nationwide population-based study

OBJECTIVE

To examine 90-day mortality among schizophrenia patients who suffered a recent stroke, using population-based data and a retrospective cohort design. Increasing evidence demonstrates a higher cardiovascular risk for schizophrenia patients compared with the general population. There are no data on stroke outcomes among schizophrenia patients.

METHODS

Data were derived from the Taiwan National Health Insurance Research Database and Cause of Death Data File in Taiwan. During 2002 to 2004, 485 schizophrenia patients hospitalized for stroke were identified. We randomly selected 2,425 stroke patients without schizophrenia who were matched to the study group on sex, age, intensive care unit admission, length of stay, and stroke type. Stratified Cox proportional hazard regressions stratified by age, sex, intensive care unit admission, length of stay, and stroke type were performed to compute the 90-day survival rate, after adjusting for demographic variables and selected medical comorbidities.

RESULTS

Among the 2,910 sampled patients, 258 patients (8.9%) died within 90 days of their index hospitalization, 18 (3.7%) from the study group and 240 (9.9%) from the comparison group (p < .001). After adjusting for demographic and comorbidity factors, stratified Cox proportional hazard regressions confirmed likewise showed that 90-day mortality was less likely among stroke patients with schizophrenia relative to stroke patients without schizophrenia (hazard ratio, 0.35; 95% confidence interval, 0.21-0.57; p < .001).

CONCLUSION

A 90-day mortality among acute stroke patients with schizophrenia is significantly lower than that of stroke patients without schizophrenia.

Risk of Stroke in Patients Hospitalized for Isolated Vertigo

Background and Purpose—

Vertigo is a common presenting symptom in ambulatory care settings, and stroke is its leading and most challenging concern. This study aimed to determine the risk of stroke in vertigo patients in a 4-year follow-up after hospitalization for acute isolated vertigo.

Methods—

The study cohorts consisted of all patients hospitalized with a principal diagnosis of vertigo (n=3021), whereas patients hospitalized for an appendectomy in 2004 (n=3021) comprised the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the 4-year stroke-free survival rate between the 2 cohorts after adjusting for possible confounding and risk factors. Among vertigo patients, there was further stratification for risk factors to identify the group at high risk for stroke.

Results—

Of the 243 stroke patients, 185 (6.1%) were from the study cohort and 58 (1.9%) were from the control group. Comparing the 2 groups, patients with vertigo symptoms had a 3.01-times (95% CI, 2.20–4.11; P <0.001) higher risk for stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. Vertigo patients with ≥3 risk factors had a 5.51-fold higher risk for stroke (95% CI, 3.10–9.79; P <0.001) than those without risk factors.

Conclusions—

Vertigo patients are at higher risk for stroke than the general population. They should have a comprehensive neurological examination, vascular risk factors survey, and regular follow-up for several years after hospital discharge after treatment of isolated vertigo.

Trace elements in bipolar disorder

INTRODUCTION

Trace elements may play an important role in bipolar disorders. The objective of this study is to determine serum copper and zinc, blood lead and cadmium and urine lead, cadmium and thallium concentrations in patients diagnosed with bipolar disorders and to compare these levels with those of a healthy control group.

MATERIALS AND METHODS

A total of 25 patients diagnosed with bipolar disorder and 29 healthy subjects participated in this study. Serum copper and zinc concentrations were measured using flame atomic absorption spectrometry; the blood lead and cadmium concentrations were measured by electrothermal atomization atomic absorption spectrometry with Zeeman background correction; urine lead, cadmium and thallium concentrations were measured by inductively coupled plasma mass spectrometry.

RESULTS

Median blood and urine lead and cadmium levels were significantly higher among the bipolar patients than among the control group: Blood lead (μg/dL): patient median: 3.00 (IQR: 1.40-4.20); control median (μg/dL): 2.20 (IQR: 0.90-3.00) p=0.040. Blood cadmium (μg/L): patient median: 0.39 (IQR: 0.10-1.15); control median: 0.10 (IQR: 0.10-0.17) p<0.001. The median of cadmium (μg/L) in patients who smoked (1.20 IQR: 0.44-2.30) was higher than that in non-smokers (0.12 IQR: 0.10-0.34) p<0.001. There was a statistically significant increase (p=0.001) in zinc levels among patients in the manic phase (mean 111.28, SD: 33.36 μg/dL) with respect to the control group (mean 86.07, SD: 12.39 μg/dL).

CONCLUSIONS

The results suggest that there could be higher levels of some toxic trace elements in the group of patients with bipolar disorder than in the healthy control group.

'Bipolar disorder' in the elderly: what's in a name?

Bipolar disorder is a chronic disorder of mood which leads to episodes of either elevated mood or depression in a sizable number of adults in the community (1%). Though the prevalence rates in the elderly are lower in the community (up to 0.1%), there is significantly higher morbidity in protected environments like care homes and hospital settings where prevalence rates may be as high as 10%. Bipolar disorder in the elderly is probably heterogenous and its etiopathogenesis is complex. Bipolar disorder may be divided into two distinct subtypes, the late onset bipolar (LOB) and the early onset bipolar (EOB) groups. LOB patients tend to have a milder illness in terms of manic severity but they have higher medical and neurological burden. They also have lower familial burden of bipolar illness as compared to EOB patients. There is an increased risk of dementia and stroke in patients with late life bipolar disorder (and there may be a protective effect of lithium in preventing dementia). White matter changes, as seen by increased white matter hyperintensities on neuroimaging, are also increased, providing further evidence of cerebrovascular disease. Treatment of late life bipolar is currently based on guidelines drawn up for younger bipolar disorder patients. Good quality intervention studies are needed to estimate the possible protective effect of cognitive enhancers and/or vascular prevention strategies. This review suggests that late life bipolar disorder, particularly late onset bipolar disorder, is probably a distinct diagnostic entity compared to the younger bipolar patients as it has a different presentation, etiology and hence perhaps needs different treatment strategies.

Cognitive dysfunction and medical morbidity in elderly outpatients with bipolar disorder

OBJECTIVE

The authors investigated the differences in cognitive function, medical burden, and sociodemographic characteristics between elderly community-dwelling bipolar patients and age-matched and education-matched normal individuals.

DESIGN

Case-control study.

SETTING

Taipei Medical University Hospital, with 75 psychiatric beds, and Taipei City Psychiatric Center-a 612-bed psychiatric teaching hospital providing comprehensive psychiatric services.

PARTICIPANTS

Eighty-two euthymic outpatients with bipolar I disorder aged older than 60 years received assessment for research purpose, 59 of whom were matched with one normal control for age and years of education.

MEASUREMENTS

All subjects had measurements of cognitive function (Clock-drawing test and Mini-Mental State Examination [MMSE]). Medical morbidity and health condition were according to the medical records, results of free annual elderly health examination, and physical examination on research interviewing.

RESULTS

Elderly bipolar patients were found to be more likely than the comparison group to have diabetes mellitus (27.1%), atopic diseases (20.3%), abnormal education-adjusted MMSE scores (32.2%), smoking habit (23.7%), and unfavorable social functioning (22%). Despite having noticeably higher heart rates, the bipolar patients' mean systolic blood pressure and prevalence of hypertension (44.1%) were significantly lower than those of the comparison group.

CONCLUSIONS

Although community-dwelling elderly patients with bipolar disorder seem to be characterized by a greater likelihood of developing cognitive dysfunction and concurrent diabetes mellitus, there is no apparent increase in the morbidity of circulatory diseases, particularly less hypertension among those without previous dementia.

Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study

BACKGROUND AND PURPOSE

No previous study has investigated the incidence or risk of cerebrovascular diseases developing after the sudden sensorineural hearing loss (SSNHL). This study sets out to estimate the risk of stroke development among SSNHL patients during a 5e-year follow-up period after hospitalization for acute episodes of SSNHL.

METHODS

Our study design features a study cohort and a comparison cohort. The study cohort consists of all patients hospitalized with a principal diagnosis of sudden hearing loss (n=1,423), whereas the control cohort comprised all patients hospitalized for an appendectomy in 1998 (n=5692) as a surrogate for the general population. Each patient was tracked from hospitalization in 1998 until the end of 2003. Cox proportional hazard regressions were performed as a means of computing the 5-year stroke-free survival rates after adjustment for possible confounding factors.

RESULTS

Of the total sample, 621 patients (8.7%) had strokes during the 5-year follow-up period: 180 (12.7% of the SSNHL patients) from the study cohort and 441 (7.8% of patients undergoing an appendectomy) from the control cohort. After adjusting for other factors, the hazard of stroke during the 5-year follow-up period was 1.64-times (95% CI, 1.31 to 2.07; P<0.001) greater for SSNHL patients than for appendectomy patients.

CONCLUSIONS

Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.

No higher risk of myocardial infarction among bipolar patients in a 6-year follow-up of acute mood episodes

OBJECTIVE

The aim of this study is to estimate the risk of acute myocardial infarction (AMI) among bipolar disorder patients during a 6-year follow-up after acute mood episodes. The risk is compared with that of a cohort of patients who underwent appendectomy operations during the same period.

METHODS

We used administrative claims data from the Taiwan National Health Insurance Research Database covering the years 1997-2002, with the two study cohorts comprising patients hospitalized for bipolar disorder (n = 1429) or appendectomies (n = 4993) in 1997. Multiple logistic regression analyses were performed to compare the crude odds ratio of patients in these cohorts developing AMI following the index discharge by gender.

RESULTS

A total of 2.24% of the bipolar disorder patients developed AMI during the 6-year follow-up period, when compared with 1.72% of the appendectomy patients. The multiple logistic regression analyses revealed that there were no significant relationships between the patients in the two cohorts developing AMI, regardless of gender.

CONCLUSIONS

There were no significant differences in the risk of developing AMI between patients with bipolar disorder and patients undergoing appendectomy operations, when compared either by gender or as whole groups.