One of the challenges of treating individuals who are diagnosed with bipolar disorder is mitigating their risk for stroke. Nearly 3 million Americans live with bipolar disorder,1 and studies suggest this disorder and other mental health conditions are associated with increased potential for stroke and higher odds of experiencing poor outcomes.2
One study found that the use of certain mood stabilizers may raise the potential for stroke, although more research is needed.3 Other factors include unhealthy lifestyle choices, poor access to care, biological factors, and chronic stress, which raises the probability of developing mood disorders and experiencing a stroke.4
Because bipolar disorder is most often treated with therapy and medications, it’s important to consider ways to decrease patients’ chances of developing stroke through clinical modifications. Pharmacists are essential to this effort.
Understanding the Factors That Put Patients at Risk
People living with bipolar disorder are twice as likely to experience a stroke, one of the most common causes of long-term disability in the United States and the fifth-leading leading cause of death, according to the American Stroke Association.5
As scientists work to uncover the root causes of stroke in people with bipolar disorder, pharmacists should pay careful attention to the health behaviors that elevate individuals’ chances of developing a stroke, as well as the potential for mood stabilizers to heighten risk.
Consider that people with bipolar disorder do not always receive the appropriate treatment and support for chronic conditions:
Male veterans with bipolar disorder face higher odds of mortality from cardiovascular disease, suggesting the need for modified treatment and patient engagement (eg, reminding patients to take their statin as well as their antipsychotic medication).6
Patients with bipolar disorder are 3 times as likely to develop diabetes—and those with type 2 diabetes also are 3 times as likely to experience rapid cycling events, even after controlling for body mass index and exposure to antipsychotic drugs.7
Depression is one of the leading causes of morbidity among people with bipolar disorder, but even with treatment, depression accounts for the majority of time patients with bipolar disorder feel unwell.8
Lack of effective interventions and support in controlling chronic disease contributes to poor health outcomes, both physical and emotional. As a result, patients with bipolar disorder have a mortality rate that is 2 to 3 times higher than that of the general population, shortening their life span by 10 to 25 years.9
Taking a Proactive Approach
To be certain, treating bipolar disorder and associated comorbid conditions effectively is highly complex. However, there are ways that pharmacists can make a substantial difference in health outcomes, particularly among patients with chronic conditions. In doing so, pharmacists can reduce patients’ risk for stroke.
Here are 4 approaches pharmacists should consider:
- Educate patients on behaviors that contribute to poor outcomes from comorbid conditions, increasing the potential for stroke. For example, while some medications can have unwanted adverse effects, understanding the impact of diet, sleep, exercise, alcohol, and tobacco use is necessary to prevent adverse health and behavioral health outcomes. Especially during the pandemic, education should be delivered in multiple formats, from telehealth to phone calls, emails, and one-to-one consultations at the point of prescription pickup, where possible. Incorporating a variety of communication techniques is crucial because the most vulnerable patients may not have access to reliable internet service during the pandemic, but they could have cell phone access.
- Use chatbots or secure texts for wellness check-ins. Chatbots could be incorporated through a pharmacy app that patients use to reorder prescriptions or through a health system app. When patients report adverse effects from their medication or general feelings of being physically unwell, pharmacists and other clinicians can respond to dig deeper. Doing so could jumpstart small changes that could enhance health outcomes. It could also improve medication adherence, another contributor to decreased stroke risk.
- Explore therapeutic options for treatment of bipolar disorder that could help reduce the potential for stroke. There have been significant advancements made in therapeutic options for the treatment of bipolar disorder in the past several years—and they are changing treatment patterns,10 with fewer patients being prescribed mood stabilizers and more patients being prescribed second-generation antipsychotics. It’s important that both patients and pharmacists understand their options, because the right approach can help eliminate the risk of stroke that is associated with certain mood stabilizers.11
- Suggest alternatives or complements to prescription medication, where appropriate. These include talk therapy, group or family therapy, and more. A recent study shows that behavioral therapy reduces episode occurrence and improves health outcomes—factors that also could lessen the likelihood of stroke.12
By taking a holistic approach to care for individuals with bipolar disorder, pharmacists can help lessen patients’ potential for stroke, improve their overall health and enhance their quality of life.
About the Author
Varun Choudhary, MD, MA, DFAPA, is a board-certified forensic psychiatrist who serves as National Behavioral Health Chief Medical Officer for Magellan Health.
- National Institute of Mental Health. Bipolar Disorder. NIMH website. https://www.nimh.nih.gov/health/statistics/bipolar-disorder. Last updated November 2017. Accessed June 9, 2021.
- Howard V. Depressive Symptoms Associated With Increased Stroke Risk. Psychiatry & Behavioral Health Learning Network. November 9, 2020.https://www.psychcongress.com/article/depressive-symptoms-associated-increased-stroke-risk. Accessed June 9, 2021.
- Rans C. Mood Stabilizers Associated With Increased Risk for Stroke in Bipolar Disorder. Psychiatry Advisor. November 5, 2018.https://www.psychiatryadvisor.com/home/topics/mood-disorders/bipolar-disorder/mood-stabilizers-associated-with-increased-risk-for-stroke-in-bipolar-disorder/. Accessed June 9, 2021.
- Hama S, Yoshimura K, Yanagawa A. Relationships between motor and cognitive functions and subsequent post-stroke mood disorders revealed by machine learning analysis. Sci Rep 10, 19571 (2020). https://doi.org/10.1038/s41598-020-76429-z.
- Chen PH, Kao YW, Shia BC, Lin HC, Kang JH. Adverse stroke outcomes among patients with bipolar disorder. PLoS ONE. 2019;14(3):e0213072. https://doi.org/10.1371/journal.pone.0213072.
- Vance MC. Psychosis, bipolar disorder may lead to worse CVD outcomes in military veterans. CardiologyToday. September 25, 2019. https://www.healio.com/news/cardiology/20190925/psychosis-bipolar-disorder-may-lead-to-worse-cvd-outcomes-in-military-veterans. Accessed June 10, 2021.
- S Calkin, Ruzickova M, Uher R, Hajek T, Slaney C, Garnham J, Alda M. Insulin resistance and outcome in bipolar disorder. British Journal of Psychiatry. 2015; 206(1), 52-57. doi:10.1192/bjp.bp.114.152850.
- McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Current Medical Research and Opinion. 2019;35:11,1993-2005. doi: 10.1080/03007995.2019.1636017.
- Hert MD, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci. 2018 Mar; 20(1): 31–40. doi: 10.31887/DCNS.2018.20.1/mdehert.
- Wilkinson ST. Study Finds Changes in the Treatment of Bipolar Disorder Over 20 Years. Brain & Behavior Research Foundation. July 2, 2020. https://www.bbrfoundation.org/content/study-finds-changes-treatment-bipolar-disorder-over-20-years. Accessed June 10, 2021.
- Rans C. Mood Stabilizers Associated With Increased Risk for Stroke in Bipolar Disorder. PsychiatryAdvisor. November 5, 2018. https://www.psychiatryadvisor.com/home/topics/mood-disorders/bipolar-disorder/mood-stabilizers-associated-with-increased-risk-for-stroke-in-bipolar-disorder/#:~:text=Exposure%20to%20carbamazepine%20was%20associated,The%20British%20Journal%20of%20Psychiatry. Accessed June 10, 2021.
- Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysis. JAMA Psychiatry. 2021;78(2):141–150. doi:10.1001/jamapsychiatry.2020.2993.