Sandra I. Ralat Rossana I. Barrios


Accumulating evidence supports the association between cardiovascular disease (CVD) risk factors and bipolar disorder (BD). CVD is the leading cause of morbidity and mortality in patients with bipolar disorder. However, there is a need to study the management of the risk factors in the primary healthcare context. This narrative review aims to appraise the different approaches of care that have been used in the management of these patients to address CVD risk factors in primary care. We reviewed articles from PubMed, Science Direct and other relevant to our search. The keywords used for this review included “bipolar,” “bipolar disorder,” “cardiovascular” or “metabolic syndrome,” “screening,” “primary care,” and “integrative” or “integrated care model” or “collaborative care model.” This review includes studies published over a period of 48 months (January 2016 through December 2019). We used the study-quality assessment tools from the National Heart, Lung, and Blood Institute to assess the quality of the articles found. CVD risk factors in patients with BD and forms of other severe mental illness (SMI) are often underdetected. Primary healthcare providers need to identify these risk factors in the management of these patients to determine and recommend appropriate strategies.



Ayerbe, L., Forgnone, I., Addo, J., Siguero, A., Gelati, S., Ayis, S. (2018). Hypertension risk and clinical care in patients with bipolar disorder or schizophrenia; a systematic review and meta-analysis. Journal of Affective Disorders, 225, 665-670.

Ayerbe, L, Forgnone, I, Foguet-Boreu, Q, González, E, Addo, J, Ayis, S. (2018). Disparities in the management of cardiovascular risk factors in patients with psychiatric disorders: a systematic review and meta-analysis. Psychological Medicine, 48(16), 2693-2701.

Bauer, I.E., Gálvez, J.F., Hamilton, J.E., Balanzá-Martínez, V., Zunta-Soares, G.B. & Meyer, T.D. (2016). Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: a systematic review. Journal of Psychiatric Research, 74, 1-7.
doi: 10.1016/j.jpsychires.2015.12.006

Bauer, M.S., McBride, L., Williford, W.O., Glick, H., Kinosian, B., Altshuler, L., Beresford, T., Kilbourne, A.M., & Sajatovic, M. (2006). Collaborative care for bipolar disorder: part I. Intervention and implementation in a randomized effectiveness trial. Psychiatric Services, 57(7):927-936.

Birkenaes, A.B., Opjordsmoen, S., Brunborg, C., Engh, J.A., Jonsdottir, H., Ringen, P.A., Simonsen, C., Vaskinn, A., Birkeland, K.I., Friis, S., Sundet, K. & Andreassen, O.A. (2007). The level of cardiovascular risk factors in bipolar disorder equals that of schizophrenia: a comparative study. Journal of Clinical Psychiatry, 68(6), 917-23.

Bobes, J., Sáiz-Ruiz, J., Montes, J.M., Mostaza, J., Rico-Villademoros, F. & Vieta, E. (2008). Spanish consensus on physical health of patients with bipolar disorder. Spanish Consensus on Physical Health of Patients with Bipolar Disorder. Revista de Psiquiatría y Salud Mental, 1:26-37.
Bodenheimer, T., Wagner, E.H. & Grumback, K. (2002). Improving primary care for patients with chronic illness. JAMA-Journal of American Medical Association, 288(14), 1775-79.

Carliner H., Collins, P.Y., Cabassa, L.J., McNallen, A., Joestl, S.S., Lewis-Fernández, R. (2014). Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review. Comprehensive Psychiatry, 55, 233-47.

Cerimele, J.M., Skern, J.S. (2017). Bipolar disorder in primary care: integrated care experiences. Focus: The Journal of Lifelong Learning in Psychiatry, 15(3), 244-248.

Compton, M.T., Daumit, G.L., Druss, B.G. (2006). Cigarette smoking and overweight/obesity among individuals with serious mental illness: a preventive perspective. Harvard Review of Psychiatry, 14(4), 212-22.

Czepielewski, L., Filho, L.D., Brietzke, E., Grassi-Oliveira, R. (2013). Bipolar disorder and
metabolic syndrome: a systematic review. Brazilian Journal of Psychiatry, 35(1), 88-92.

Damegunta, S.R., Gundugurti, P.R. (2017). A cross-sectional study to estimate cardiovascular risk factors in patients with bipolar disorder. Indian Journal of Psychological Medicine, 39(5): 634-640. doi: 10.4103/IJPSYM.IJPSYM_369_17

Daviglus, M.L., Pirzala, A., Talavera, G.A. (2014). Cardiovascular disease risk factors in the Hispanic/Latino population: lessons from the Hispanic community health study/Study of Latinos (HCHS/SOL). Progress in Cardiovascular Diseases, 57, 230-236.

Derby IM. (1933). Manic-depressive “exhaustion” deaths: an analysis of “exhaustion” case histories. Psychiatric Quarterly, 7, 436–49.
Druss, B.G., Zhao, L., Esenwein, S.V., Morrato, E.H., Marcus, S.C. (2011). Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical Care. 2011; 49:6, 599-604.

Druss, B.G., von Esenwein, S.A., Glick, G.E., Deubler, E., Lally, C., Ward, M.C. & Rask, K.J. (2017). Randomized trial of an integrated behavioral health home: the health outcomes management and evaluation (HOME) study. American Journal of Psychiatry, 174(3), 246-255.

Emilien, G., Septien, L., Brisard, C., Corruble, E., Bourin, M. (2007). Bipolar disorder: How far are we from a rigorous definition and effective management? Progress in Neuro-Psychopharmacology & Biological Psychiatry, 31(5), 975-996.

Fiedorowicz, J.G., Jancic, D., Potash, J.B., Butcher, B., & Coryell, W.H. (2014). Vascular mortality in participants of a bipolar genomics study. Psychosomtics, 55(5), 485-90.

Fiedorowicz, J.G., Solomon, D.A., Endicott, J., Leon, A.C., Li, C., Rice, J.P. & Coryell, W.H. (2009). Manic/Hypomanic symptom burden and cardiovascular mortality in bipolar disorder. Psychosomatic Medicine, 71(6), 98-606. doi: 10.1097/PSY.0b013e3181acee26

Firth, J., Veronese, N., Cotter, J., Shivappa, N., Hebert, J.R., Ee, C., Smith, L., Stubbs, B., Jackson, S.E. & Sarris, J. (2019). What is the role of dietary inflammation in severe mental illness? A review of observational and experimental findings. Frontiers in Psychiatry,, 10, 1-9. doi: 10.3389/fpsyt.2019.00350

García-Portilla, M., Saiz, P., Bascaran, MT, Martínez, S., Benabarre, A., Sierra, P., Torres, P., Montes, J.M., Bousoño, M. & Bobes, J. (2009). Cardiovascular risk in patients with bipolar disorder. Journal of Affective Disorders, 115, 302-308.

Goldstein, B.I., Fagiolini, A., Houck, P. & Kupfer, D. (2009). Cardiovascular disease and hypertension among adults with bipolar disorder in the United States. Bipolar Disorders An International Journal of Psychiatry and Neurosciences, 11(6), 657-662.

Goodrich, D.E., Kilbourne, A.M., Lai, Z., Post, E.P., Bowersox, N.W., Mezuk, B., Schumacher, K., Bramlet, M., Welsh, D.E. & Bauer, M.S. (2012). Design and rationale of a randomized controlled trial to reduce cardiovascular disease risk for patients with bipolar disorder. Contemporary Clinical Trials, 33(4), 666-678.

Hayes, J.F., Marston, L., Walters, K., King, M.B., Osborn, D.P.J. (2017). Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000-2014. British Journal of Psychiatry, 211(3), 175-181.

Kalelioğlu, T, Ünalan, P, Kök B., Sözen, S., Yüksel, Ö., Akkuş, M., Cihnioğlu, R., Karamustafalıoğlu, N. (2018). Atherogenic index of plasma as a cardiovascular risk marker in manic, depressive and euthymic stages of bipolar disorder. Archives of the Turkish Society of Cardiology, 46(1), 32-38.

Kilbourne, A.M., Post, E.P., Nossek, A., Sonel, E., Drill, LJ., Cooley, S. & Baer, M.S. (2008). Service delivery in older patients with bipolar disorder: a review and development of a medical care model. Bipolar Disorders An International Journal of Psychiatry and Neurosciences, 10, 672–683.

Kilbourne, A.M., Goodrich D.E., Lai, Z., Post, E.P., Schumacher, K., Nord, K.M., Bramlet, M. Chermack, S., Bialy, D & Bauer, M.S. (2013). Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: The Self-Management Addressing Heart Risk Trial (SMAHRT). Journal of Clinical Psychiatry, 74(7), 655–662.

Kilbourne, A.M., Barbaresso, M.M., Lai, Z., Nord, K.M., Bramlet, M., Goodrich, D.E., Post, E.P., Almirall, D. & Bauer, M.S. (2017). Improving physical health in patients with chronic mental disorders: 12-month results from a randomized controlled collaborative care trial. Journal of Clinical Psychiatry, 78(1), 129-137.

Kilbourne, A.M., Beck, K., Spaeth-Rublee, B., Ramanuj, P., O’Brien, R.W., Tomoyasu, N. & Pincus, H.A. (2018). Measuring and improving the quality of mental health care: a global perspective. World Psychiatry, 17, 30-38.

Lambert, M. Ruppelt, F., Siem, A.K., Rohenkohl, A.C., Kraft, V., Luedecke, D., Sengutta, M., Schroter, R., Daubmann, A., Correll, C.U., Gallinat, J., Karow, A., Wiedemann, K. & Schottle, D. (2018). Comorbidity of chronic somatic diseases in patients with psychotic disorders and their influence on 4-year outcomes of integrated care treatment (ACCESS II Study). Schizophrenia Research, 193, 377-383.

Lopresti, A.L. & Jacka, F.N. (2015). Diet and bipolar disorder: a review of its relationship and potential therapeutic mechanisms of action. Journal of Alternative and Complementary Medicine, 21(2), 733-9.

Martin, D.J., Ul-Haq, Z., Nicholl, B.I., Cullen, B., Evans, J., Gill, J.M., Roberts, B., Gallacher, J., Mackay, D., McIntosh, A., Hotopf, M., Craddock, N., Deary, I.J., Pell, J.P. & Smith, D.J. (2016). Cardiometabolic disease and features of depression and bipolar disorder: popultion-based, cross-sectional study. The British Journal of Psychiatry, 208(4), 343-51.

McIntyre, R.S. (2009). Understanding needs, interactions, treatment, and expectations among individuals affected by bipolar disorder or schizophrenia: the UNITE global survey. Journal of Clinical Psychiatry, 70(3):5-11.

Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine 6(6), e1000097. doi:10.1371/journal.pmed1000097

Murray, D.P., Weiner, M., Prabhakar, M. & Fiedorowicz, J. (2009). Mania and mortality: why the excess cardiovascular risk in bipolar disorder? Current Psychiatry Report, 11(6), 475-480.

National Heart, Lung, and Blood Institute. 2016. Study Quality Assessment Tools. Accessed October 2018.

Nielsen, R.N., Kugathasan, P.K., Straszek, S., Jensen, S.E., Licht, R.W. (2019). Why are somatic diseases in bipolar disorder insufficiently treated? International Journal of Bipolar Disorders, 7(12), 1-7.

Osborn, D., Burton, A., Hunter, R., Marston, L., Atkins, L., Barnes, T., Blackburn, R., Craig, T., Gilbert, H., Heinkel, S., Holt, R., King, M., Michie, S., Morris, R., Morris, S., Nazareth, I., Omar, R., Petersen, I., Peveler, R., Pinfold, V. & Walters, K. (2018). Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: a cluster randomized controlled trial. The Lancet Psychiatry, 5, 145-154.

Pérez-Piñar, M, Mathur, R, Foguet, Q, Ayis, S, Robson, J, Ayerbe, L. (2016). Cardiovascular risk factors among patients with schizophrenia, bipolar, depressive, anxiety, and personality disorders. European Psychiatry, 35, 8-15.

Ralat, S.I., Depp, C.A., Bernal, G. (2018). Reasons for nonadherence to psychiatric medication and cardiovascular risk factors treatment among latino bipolar disorder patients living in Puerto Rico: a qualitative study. Community Mental Health Journal, 54(6), 707-716.

Ramsey, C.M., Leoutsakos, J.M., Mayer, L.S., Eaton, W.W. & Lee, H.B. (2010). History of manic and hypomanic episodes and risk of incident cardiovascular disease: 11.5 follow-up from the Baltimore Epidemiologic Catchment Area Study. Journal of Affective Disorders, 125(1-3), 35-41.

Ritchie, S., Muldoon, L. (2017). Cardiovascular preventive care for patients with serious mental illness. Canadian Family Physician, 63, 483-487.

Russo, C.A., Andrews, R.M. (2006). The national hospital bill: the most expensive conditions, by payer, 2004. HCUP Statistical Brief #13. Agency for Healthcare Research and Quality, Rockville, Md.

Shrivastava, A., Johnston, M.E. (2010). Weight-gain in psychiatric treatment: risks, implications, and strategies for prevention and management. Mens Sana Monographs, 8(1), 53-68.

Slomka, J.M., Piette, J.D., Post, E.P., Krein, S.L., Zongshan, L., Goodrich, D.E. & Kilbourne, A.M. (2012). Mood disorder symptoms and elevated cardiovascular disease risk in patients with bipolar disorder. Journal of Affective Disorders, 138, 405-408.

Swartz, H.A., Fagiolini, A. (2012). Cardiovascular disease and bipolar disorder: risk and clinical implications. Journal of Clinical Psychiatry, 73(2), 1563-5.

Tepper, M.C., Cohen, A.M., Progovac, A.M., Ault-Brubus, A., Leff, H.S., Mullin, B., Chunningham, C.M. & Cook, B.L. (2017). Mind the gap: developing an integrated behavioral health home to address health disparities in serious mental illness. Psychiatric Services, 68(12), 1217-24

UCL Psychiatry (2020). The PRIMROSE Programme of Research.
U.S. Department of Health and Human Services. (2008). The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020.

Vancampfort, D., Vansteelandt, K., Correll, C.U., Mitchell, A.J., De Herdt, A., Sienaert, P., Probst, M. & De Hert, M. (2013). Metabolic syndrome and metabolic abnormalities in bipolar disorder: a meta-analysis of prevalence rates and moderators. American Journal of Psychiatry, 170(3), 265-274.

Vancampfort, D., Firth, J. & Schuch, F. (2016). Physical activity and sedentary behavior in people with bipolar disorder: a systematic review and meta-analysis. Journal of Affective Disorders, 201, 145-152.

Vuksan-Cusa, B., Marcinko, D., Sagud, M., Jakovljevic, M. (2009). The comorbidity of bipolar disorder and cardiovascular diseases from pharmacotherapy perspective, Psychiatria Danubina, 21(3): 382-385.

Walkers, E.R., McGee, R.E., Druss, B.G. (2015). Mortality in mental disorders and global
disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry, 72(4), 334-341. doi:10.1001/jamapsychiatry.2014.2502.

Wiener, M., Warren, L., Fiedorowicz, J.G. (2011). Cardiovascular morbidity and mortality in bipolar disorder. Annals of Clinical Psychiatry, 23(1), 40-47.

Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A.M. & Bauer, M.S. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. American Journal of Psychiatry, 169(8), 790-804.
Cómo citar
The management of cardiovascular disease risk factors in bipolar disorder patients in primary healthcare settings. (2020). Revista Puertorriqueña De Psicologia, 31(1), 62-78.
Artículo de investigación

Cómo citar

The management of cardiovascular disease risk factors in bipolar disorder patients in primary healthcare settings. (2020). Revista Puertorriqueña De Psicologia, 31(1), 62-78.