With Increase in Bipolar Patients the VA Tackles Medication Side Effect Issues

By Steve Lewis

BOSTON–Headlines may focus on mental-health issues such as schizophrenia, often related to veteran homelessness or even violent behavior, but bipolar disorder actually is increasing far faster at the VA and can be especially challenging to treat because of the high side-effect profile of the drug commonly used to treat it.

Bipolar disorder “has been an orphan disorder; it’s fallen between the cracks,” said Mark S. Bauer, MD, professor of psychiatry, Harvard Medical School, and associate director, Center for Organization, Leadership and Management Research (COLMR), at the VA Boston Healthcare System.

– Mark S. Bauer, MD. Professor of pschiatry, Harvard Medical School

In research he called “very compelling,” Bauer said prevalence of cases increased from 77,000 to more than 106,000 at the VA between 2002 and 2008 – more than a 37% increase.

“At the same time, there has been a flattening or reduction of the number veterans treated for schizophrenia, from about 86,000 to about 71,000,” he noted.

One of the few occasions when bipolar disorder was in the news lately concerned research on the toxicity of lithium, the treatment of choice for more than 50 years. Research published in the journal The Lancet earlier this year reaffirmed that lithium “is associated with increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism and weight gain.”

The authors also affirmed, however, that lithium should continue to be the first-line treatment for bipolar disorder, despite challenges in managing medication side effects.

“This article was extremely high quality,” Bauer asserts. “What’s important to understand is the reason it was written is that there has been a rebirth in interest in lithium as newer drugs have come to be seen as pretty good alternatives.”

While lithium is an anti-manic medication, so are others such as divalproex, he noted. Yet, there are few alternatives to lithium in treating depression in bipolar patients.

“Probably the strongest data for an anti-depressant effect is with lithium, and there is also a lot of evidence that lithium has a specific anti-suicide effect,” he asserted, adding that, side effects to the contrary, “there are many reasons for providers to increase their use of lithium.”

An article published in 2010 in the Archives of General Psychiatry suggested that the single diagnosis most highly associated with successful suicide is bipolar disorder, “So there is a huge mortality risk, and the number of patients is increasing,” Bauer pointed out.

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