Is Bipolar Disorder Partly a Vascular Disease?

Heather is 43-year-old woman with bipolar disorder attending her follow-up appointment in your clinic. You have been treating her since her first hospitalization for mania a decade ago. Whether it is depression, mania, anxiety, or the occasional intervals of excessive alcohol use, each appointment brings a new treatment target. Thankfully, Heather has finally enjoyed an extended recovery from her mood symptoms for the past 2 years. You are surprised to learn that, since your last appointment, Heather has, despite her young age, experienced a relatively significant myocardial infarction.

The above scenario is not as uncommon as we might hope, according to data from a recent study that my colleagues and I conducted of the incidence of new-onset cardiovascular disease in a large, representative, epidemiologic sample of the United States population. In this study, adults with bipolar I or II disorder were markedly more likely than either adults without mood disorders or those with major depressive disorder to be diagnosed with new-onset cardiovascular disease between baseline and 3-year follow-up. Additionally, new-onset cardiovascular disease occurred extremely prematurely among adults with bipolar disorder—on average, 8–11 years earlier than in adults with major depressive disorder and 14–17 years earlier than in adults without mood disorders. The question arises, why?

Among people with bipolar disorder, rates of cardiovascular risk factors, such as smoking and obesity, are higher than in the general population. The physiologic strain of mania and depression may contribute to the excessive burden of heart disease in bipolar disorder. Many of the medications used to treat bipolar disorder also precipitate weight gain and other metabolic disturbances that contribute to cardiovascular risk. But maybe all of these considerations are only part of the story. Maybe bipolar disorder and cardiovascular disease have shared etiopathology, ie, they are geographic strangers but mechanistic family.

In our study, many people with bipolar disorder had never received treatment for their condition, and most had never received antimanic medications, suggesting that these findings cannot be explained by medications alone. This was not a highly distilled sample of patients in tertiary care settings but rather a representative community sample. The large sample afforded us the rare luxury of controlling for many potential confounding variables. Even after taking into account demographic variables, smoking, obesity, hypertension, and alcohol and drug use disorders, the odds of people with bipolar disorder developing cardiovascular disease were twice that of people with major depressive disorder and over two and a half times that of the general population without mood disorders.

What does this all mean? Clearly, we need to help patients optimize their lifestyle, and we need to minimize the metabolic burden conferred by our medications. But we also need to recognize—in our conceptualizing of bipolar disorder, in our advocacy efforts toward reducing stigma, and in the design of envelope-pushing clinical trials and biological research—that bipolar disorder is in part a vascular disease and needs to be approached as such.

Financial disclosure:Dr Goldstein had no relevant personal financial relationships to report.​