Patients with bipolar illness admitted to a general medical service.

ABSTRACT

Background. This study was done to assess the size and characteristics of the patient population with bipolar illness treated on the general medical service of two divisions of the Charleston Area Medical Center, the largest hospital complex in West Virginia.

Methods. A total of 779 admitting and/or discharge summaries were reviewed.

Results. The average age of the manic patients (50.5 years) was lower than that of schizophrenic patients (56.1 years) or the general population (58.9 years). The most common reasons for admission in the manic group were chest pain (5 patients) and drug overdose (4 patients). Alcohol abuse was more common in the bipolar group (20%) than in the schizophrenic group (11%) or the general population (12%).

Conclusions. Additional studies of the prevalence of bipolar disorder in West Virginia are warranted.

THE DIAGNOSIS AND TREATMENT of bipolar disease is a challenge to health care providers. The current study was done to determine whether bipolar illness is a public health problem in West Virginia that warrants additional research, even though a literature search yielded no previous publications focusing on manic-depressive (bipolar) disorder among West Virginia residents. The size and characteristics of the patient population treated for bipolar illness by the general medical service of the Memorial and General divisions of the Charleston Area Medical Center (West Virginia's largest hospital complex) were therefore documented.

METHODS

Information used for this study was obtained from review of 779 admitting and/or discharge summaries of internal medicine physicians at the West Virginia University School of Medicine/Charleston Division, who served sequentially from 1995 to 1999 as attending physicians on the general medical service for several months of the year. Because general medicine attending service by these physicians was not consistently restricted to specific seasons, the data are multiseasonal.

Categorization of certain patients as bipolar or schizophrenic was based on psychiatric diagnoses established before admission on the medical service (or during admission after behavioral medicine consultation) by history from patients or patient family members or from hospital records. Two patients with mild mental retardation in addition to schizophrenia were included in the schizophrenic group.

RESULTS

Of the 779 patients considered in this study, 25 (3%) were known to have bipolar disorder. The bipolar group included 11 men and 14 women (average age, 50.5 years; range, 28 to 82 years). The most common reasons for admission among manic-depressive patients included chest pain (5 patients--3 men and 2 women) and drug overdose (4 patients, all women; 2 lithium overdoses, 1 Tylenol overdose, 1 antidepressant overdose). Two bipolar women were admitted because of fracture. Of the 25 patients with bipolar disorder, 5 (20%) had abused alcohol within 6 months of the time of admission, and 11 (44%) used nicotine products.

Of the 779 patients considered in this study, 9 (1%) were known to have schizophrenia (3 men, 6 women; average age, 56.1 years; range, 39 to 66 years). The most common reasons for admission among the schizophrenics were shortness of breath/respiratory failure (2 women and 1 man) and chest pain (2 women); no overdose admissions were noted in this group. Of the 9 schizophrenics, 3 (33%) were known to use nicotine products, and 1 (11%) was known to abuse alcohol.

Of the 745 patients without bipolar disease or schizophrenia (354 men, 391 women; average age, 58.9 years; range, 16 to 100 years), 15 patients (9 men, 6 women) were admitted because of overdose, 150 (20%) were admitted for chest/nontraumatic upper body pain, 264 (35%) used nicotine products, and 86 (12%) had abused alcohol within 6 months of the time of admission.

DISCUSSION

This study detected more than twice as many cases of bipolar disease as schizophrenia among admissions to the general medical service. The manic-depressive patients were, on average, younger than the schizophrenics or the patients with other nonbipolar disorders, while the sex ratio was unremarkable in all groups. The fact that patients in the bipolar group were younger but were about as frequently admitted with chest pain may reflect increased demands on the cardiovascular system in patients with manic agitation.

The admissions for drug overdose appeared to follow a seasonal pattern, with 7 of the 19 overdoses (37%) occurring in November, 7 in March, and 1 each in January, February, May, June, and September. This is consistent with the observation dating back to Hippocrates that melancholia (which may result in intentional overdoses) is more likely to occur in spring and autumn. These are peak times for hospital admissions for depression, (1) and this seasonal pattern may be especially evident in rural areas. (2)

Compared with the patients who were not bipolar or schizophrenic, a larger proportion of persons in the bipolar group were known to be alcohol abusers. This is congruent with literature suggesting that self-medication with alcohol is sometimes used by patients with mania to control agitation. (3)

Underdiagnosis of bipolar illness remains widespread, and this may result in inappropriate treatment and subsequent deterioration of the condition. Bipolar patients are frequently thought to be suffering only from depression because (1) mild manias may not be perceived by patients as pathologic; (2) depression is more likely to motivate a patient to seek or accept clinical care; and (3) clinicians may be unaware that mood volatility and irritability are often signs of bipolar illness, and they may not inquire about other symptoms (eg, sleeplessness, spending sprees, increased sexual activity) or ask whether there is a family history of mood swings or suicidal acts that are pertinent to the bipolar diagnosis. Many internists are more comfortable prescribing antidepressants than mood-stabilizing drugs such as lithium. However, antidepressants may precipitate mania or agitation in persons with bipolar disorder. (4) Whether widespread and casual administration of antidepressants is resulting in more manifestatio ns of bipolar illness among genetically susceptible persons in West Virginia warrants additional investigation.

References

(1.) Suhail K, Cochrane R: Seasonal variations in hospital admissions for affective disorders by gender and ethnicity. Psychiatry Psychiatr Epidemiol 1998; 33:211.217

(2.) Durkheim E: Suicide: A Study in Sociology. New York, Free Press, 1951 (first published 1897)

(3.) Kessler RC, Nelson CB, McGonagle KA, et al: The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatmy 1996; 50:36-43

(4.) Jamison KR: Night Falls Fast: Understanding Suicide. New York, Knopf, 1999, pp 235-263

RELATED ARTICLE: KEY POINTS

* The most common reasons for admission among manic-depressive patients included chest pain (5 patients--3 men and 2 women) and drug overdose (4 patients, all women; 2 lithium overdoses, 1 Tylenol overdose, 1 antidepressant overdose).

* The most common reasons for admission among the schizophrenics were shortness of breath/respiratory failure (2 women and 1 man) and chest pain (2 women); no drug overdose admissions were noted in this group.

* This study detected more than twice as many cases of bipolar disease as schizophrenia among admissions to the general medical service. The manic-depressive patients were, on average, younger than the schizophrenics or the patients with other nonbipolar disorders, while the sex ratio was unremarkable in all groups.

* Compared with the patients who were not bipolar or schizophrenic, a larger proportion of persons in the bipolar group were known to be alcohol abusers.

From the Department of Medicine, West Virginia University School of Medicine/Charleston Division.

Reprint requests to Lynn w. Kitchen, MD, MPH, 4309 Embassy Park Dr NW, Washington, DC 20016-3606.