Treatment Delays in Bipolar Disorders

To the Editor: In their report on selected DSM-III-R disorders, Ronald C. Kessler, Ph.D., and colleagues found that median delays from illness onset to treatment ranged from a year for DSM-III-R panic disorder and 6 years for depression to several decades for phobias (1). Since bipolar disorders are very common and account for much disability and mortality and enormous economic costs (2, 3), the timing of their appropriate treatment is also important for clinical and public health policies.

Accordingly, we analyzed the time to lithium treatment in 345 DSM-IV bipolar I and II disorder patients reported elsewhere with times for additional patients from the same center who had given written informed consent (3). Time from illness onset to maintenance treatment averaged 8.38 years (SD=8.33), at 7.28 years (SD=7.68) versus 10.03 years (SD=9.00) for type I (N=207) versus type II (N=138) syndromes, and 7.02 years (SD=7.32) versus 9.14 years (SD=8.77) in men (N=124) versus women (N=221). Latencies ranged from 6.87 years (SD=7.68) in bipolar I men to 11.00 years (SD=9.51) in bipolar II women, possibly reflecting varying urgency in clinical presentations. We tested for the effects of diagnosis and sex by two-way, log-normalized ANOVA (overall F=6.83, df=2, 342, p=0.0012; for types I and II, F=11.2, df=2, 342, p=0.0009; for sex, F=1.06, df=2, 342, n.s., without significant interaction, F=1.36, df=2, 342, n.s.).

Since lithium is the only mood-altering medication with substantial evidence for antisuicidal effects (2), it is a matter of particular concern that 73.5% (50 out of 68) first life-threatening suicide attempts occurred within the 8.38-year latency to lithium maintenance therapy (2). These findings further encourage 1) timely identification of bipolar disorders, including their often misdiagnosed juvenile antecedents and type II presentations; 2) research to define safe and effective treatment for bipolar depression; and 3) earlier therapeutic intervention in these commonly misdiagnosed and often lethal disorders.