Although the cause of Carrie Fisher’s death was reportedly a massive heart attack, one could say that she actually died of bipolar disorder. It is well known that heart disease is society’s leading killer. In contrast, it is largely unrecognized that people with bipolar disorder are at particularly high risk of heart disease. Shining a light on the heart-bipolar connection serves a number of important parallel purposes, including the promotion of assertive approaches to optimizing heart health, reducing the ongoing stigma toward bipolar disorder and other forms of mental illness, and encouraging further research efforts on this topic.

Carrie Fisher was not only a luminary artist, she was also a luminary advocate for mental health, focusing especially on bipolar disorder, a condition from which she suffered. Because of Ms. Fisher’s profession and talents, hers is an epic and singular story that has and will continue to touch the world for many years. But hers is also a typical story, albeit tragically so, of a young woman who experienced the onset of bipolar disorder early in life, who survived decades of the effects of bipolar disorder on her mind and brain, and who, it could be said, was ultimately felled by the impact of bipolar disorder on her heart.

Based on the most recent data from the United States general population, not only are people with bipolar disorder more likely to have heart disease, they also experience heart disease up to 17 years earlier, on average, than people who do not suffer from mood disorders. A sixty year-old woman with bipolar disorder may have the heart of a mentally healthy woman in her late seventies. The extent to which bipolar disorder increases and accelerates the risk of heart disease exceeds what can be explained by smoking, drug and alcohol use, sedentary lifestyle, nutrition, physical side effects of psychiatric medications, and even traditional heart disease risk factors such as high blood pressure and obesity. All of these factors are particularly common among people with bipolar disorder, but they are only part of the story.

Almost certainly, the distress caused by the symptoms of bipolar disorder, alongside the stress caused by the impact of those symptoms on people’s lives, contributes in part to elevated heart disease risk. There are a number of biological processes that could form the heart-bipolar bridge, including elevated levels of inflammatory markers, which have been shown to coincide with the episodes of mania and depression that define bipolar disorder and which increase the risk of heart disease.

Studies have also found evidence of poor blood vessel health among people with bipolar disorder, in the brain as well as the body. The scientific literature on this topic is so compelling, and yet so under-recognized, that a recent scientific statement from the American Heart Association positioned bipolar disorder (as well as major depressive disorder) among youth as a risk factor for early heart disease.

It is worth noting that among teenagers, bipolar disorder is twice as common among girls than boys. It is also worth noting that the extent of increased risk of heart disease attributable to bipolar disorder is even greater for females than it is for males. In losing Carrie Fisher, the world has lost a warrior princess who gifted us with valiant efforts both on and off the screen. As we each consider the ways in which we will honor her memory, let us consider all of the young warrior princesses (and princes) with bipolar disorder for whom the prospects of a long and healthy life rest on early and assertive approaches to heart health.

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At the Centre for Youth Bipolar Disorder at Sunnybrook, we often see teens with relatively longstanding and/or severe symptoms who have never been treated, often because their symptoms have been misattributed to the angst, stress, hormones, or parent-child tensions of adolescence. Whereas these issues affect most everyone, 19 out of 20 teens don’t have bipolar disorder. 

Bipolar disorder vs. “teen-itis”

So what’s the difference between bipolar disorder and a bad case of “teen-itis?” Briefly, a diagnosis of bipolar disorder requires that someone has had “episodes” of mania or milder hypomania, usually alternating with depression episodes. These mood episodes are defined by a cluster of symptoms that cause a change in day-to-day functioning, generally lasting days to weeks for mania/hypomania and weeks to months or even years for depression. Many teens have “great days” with very happy mood, lots of productivity, and perhaps boosted energy. But on those days do they also make uncharacteristic, risky decisions? Lose their need for sleep? Talk so much and so fast that they can’t be interrupted? When these symptoms cluster, persist, and change behaviour, it’s time to carefully consider diagnoses other than “teen-itis.”

Bipolar disorder as a mental illness

Another theme that needs to be demystified is the concept of bipolar disorder as a “mental” illness. Bipolar disorder is a mental illness, of course, but only because we define it that way. In fact, the symptoms are the end result of environmental factors interacting with genetic factors to produce biological disturbances that cause these symptoms. The same is true for most complex diseases. There are clinically useful objective tests for arthritis, cancer, and diabetes, which make these diseases “real.” There are no tests for bipolar disorder. So is it “real”? Of course it is. Bipolar disorder runs in families, responds to specific treatments, and is different from other disorders (despite some overlapping symptoms, which is a topic for another day). But there are no tests for bipolar disorder, only tests to rule out other medical conditions. Why does this matter? Without tests or “biomarkers,” it is hard to predict the course of bipolar disorder, predict and measure treatment response, or predict who is going to develop bipolar disorder in the future.

But perhaps the biggest problem caused by the lack of tests for bipolar disorder is stigma. Although bipolar disorder is the fourth most disabling condition among teens worldwide, and despite Canada’s national health care system, most teens with bipolar disorder have never been treated for bipolar disorder. Lack of recognition of bipolar disorder in teens, and reluctance to seek care as a result of stigma, are two major barriers to receiving care. Our hope is that demystifying bipolar disorder through education and research will help pave a smoother road for teens and families.

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In recent years, Heather and her husband, Rick, have been increasingly concerned about their children, and about the possibility that they may have bipolar disorder in the future. Justin has always been an easy-going guy, but he had a month-long depression after a break-up with his girlfriend last year, and since then has had another episode of depression that appeared to come “out of the blue.” Alex has had an anxious temperament since toddlerhood, and in recent years has had pronounced social anxiety and frequent panic attacks. Although cognitive-behavioral therapy has been helpful, she remains with distressing symptoms that impair her functioning. Heather and Rick are concerned, and would like to know more about the risk for bipolar disorder in their children, and whether Heather’s diagnosis weighs into decisions about possible pharmacological treatment for their children’s symptoms.

The above anecdote reflects a common occurrence, as many adults with bipolar disorder have children, and many of those children demonstrate some form of psychiatric symptoms, including anxiety, depression, inattention, or significant irritability and mood swings. Several details of the anecdote are worth highlighting, as Heather’s experience with bipolar disorder was very typical. For example, most people who are eventually diagnosed with bipolar disorder have prior problems with anxiety and/or depression. The average delay between onset of bipolar disorder symptoms and diagnosis and treatment of bipolar disorder is about 10 years, and the earlier the onset of bipolar disorder, the longer the delay. Furthermore, although problems such as anxiety and mood swings are common in teenagers, they are especially common among teenagers whose parents have bipolar disorder. This raises important treatment implications. Whereas standard antidepressants such as Prozac are often effective and generally safe for treating teens with anxiety or depression, antidepressants can occasionally trigger a manic episode in teens and this risk is higher in teens who have a parent with bipolar disorder. The same is true, although perhaps somewhat less so, for ADHD medications such as Ritalin.

This leaves treatment providers, teens, and their families with three main options: 1) “watch and wait” (i.e. no medications); 2) use the same treatment approach that would be used in the absence of parental bipolar disorder; or 3) treat with the same medications one would use if the teen already had bipolar disorder. Each of these options has its benefits and drawbacks. Watching and waiting avoids treatment-related risks, but incurs risk of untreated symptoms and possible progression into bipolar disorder. Using antidepressant or stimulant medications often reduces symptom burden, but incurs the risk of medication-induced mania. Finally, using bipolar disorder medications such as lithium or antipsychotics often improves symptoms, and provides some protection against mania, but incurs increased risk of side-effects including weight gain and other physical problems.

When I work with families in this scenario, I modify my treatment approach in several ways. First, I raise my threshold for prescribing. That is, I encourage therapy as a first-line approach even more so than I do for other patients. Second, I underscore the importance of healthy lifestyle and focus on establishing regular sleep-wake, eating, and exercise schedules. I also underscore the accentuated risk of certain biological and environmental stressors. For example, use of alcohol, marijuana, and other substances, is an especially risky endeavor among teens such as Alex and Justin. Similarly, although family stress is not fun for anyone, it is an especially important aspect of care to consider in this circumstance. Indeed, there is promising evidence that a type of family-focused therapy that targets offspring of parents with bipolar disorder may reduce early mood symptoms by optimizing family communication and problem-solving skills. Third, I provide education about the symptoms of mania (so that families are aware when to seek urgent treatment), and about the natural course of bipolar disorder. I address questions relating to the likelihood of developing bipolar disorder during adolescence and young adulthood for these offspring (about 10-20%), the extent of increased risk for bipolar disorder among teenage offspring of parents with bipolar disorder (10-fold increase), and factors that increase risk of bipolar disorder in this high-risk population (e.g. anxiety, depression, and significant irritability and mood swings).

Bipolar disorder is arguably the most familial psychiatric condition, with up to 90% of the risk for bipolar disorder explained by heritability. As such, teens who have a parent with bipolar disorder have unique assessment and treatment needs. Although the concept of early identification and appropriate treatment preventing bipolar disorder has yet to be conclusively supported by careful research, it most certainly passes the logic test. Taking together what we know and what we don’t yet know, I’m of the opinion that symptomatic teenage offspring of parents with bipolar disorder warrant a careful psychiatric evaluation that addresses all of the above nuances and is customized to the unique needs of these teens.

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Diagnosing bipolar disorder in teenagers is often even more challenging than in adults. Compared to adults with bipolar disorder, teenagers with bipolar disorder are more often symptomatic, have more changes in mood “polarity” (depression to mania and vice versa), and have more comorbid conditions. Normal adolescence presents another challenge, as it is often characterized by more mood swings, impulsivity, hormonal flux, and less consistent nutritional, sleep and social rhythms, as compared to adulthood. 

Finally, prevailing attitudes about bipolar disorder further complicate diagnosis. Despite recent progress, stigma remains a meaningful barrier. Even severe symptoms are often attributed to so-called “teenage angst” or “poor parenting”. There is ongoing skepticism about the legitimacy of bipolar disorder (and other psychiatric disorders). Improving the future for teens and families affected by bipolar disorder will require a concerted effort between teens, families, health professionals, scientists, advocacy groups, the media and policy makers.

Meanwhile, parents and families can make a difference by arming themselves with knowledge about bipolar disorder. To that end, here are a couple of facts and tips to consider when deciding whether a moody teenager may need professional evaluation for bipolar disorder:

Fact: Mania is more than a mood swing.

Manic episodes are characterized by elation and/or irritability, accompanied by increased energy/activity and several other symptoms such as reduced need for sleep, increased distractibility, faster speaking and thinking and increased productivity. Episodes often last from days to weeks, comprise a change from normal behavior and can lead to dangerous decision making.

Tip: Think of mania as C-D-E.

C: symptoms are Concurrent/Clustered. D: symptoms are Durable, not just fleeting. E: symptoms are Episodic, and are different from the teen’s usual behavior.

Fact: 1% of teens have classical bipolar disorder with severe manic episodes lasting a week or longer, and up to 5% of teens will experience shorter and/or less severe episodes. Up to 50% of these teens will develop classical bipolar disorder, and for those who don’t, these symptoms could still suggest the need for different types of treatment than would otherwise be chosen.

Tip: If your teen is currently suffering from depression or anxiety, but has previously had even brief episodes such as those described above, be sure to describe these episodes to your teen’s doctor or therapist.

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What can people living with bipolar disorder do to minimize weight gain, or even lose weight that has already been gained? Simplicity is of the essence, because people with bipolar disorder often already juggle multiple competing demands, and they rarely have the luxury or opportunity to engage in a time-consuming intervention focusing specifically on weight.

Colleagues in the field of pediatrics have identified a “Big 5” list of modifiable risk factors for obesity among the general population of youth, and as you can see, most of these strategies could equally apply for adults:

1. Limit sweetened beverage intake (including juice, soft drinks) to one serving per day.
2. Limit television and other screen time to 2 hours per day.
3. Limit fast food intake to one meal per week.
4. Strive for 60 minutes of moderately vigorous physical activity most days of the week.
5. Strive to eat meals as a family as much as possible.

Whether using the above strategies or other approaches, it is advisable to focus on dietary intake and physical activity before weight gain has occurred. When starting a medication, much of the excessive weight gain occurs in the first 12 weeks. Efforts aimed at limiting weight gain are especially important in these early weeks of treatment. Preventing excessive weight gain is not only beneficial from a medical perspective, but it can also help ensure that people continue to take their medication on a regular basis so as to derive the greatest possible benefit. 

For more info on childhood obesity, visit the American Family Physician website.

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