Byline: Roger S. McIntyre, MD, Joanna K. Soczynska, and Jakub Konarski

Bipolar disorder (BD) is a highly prevalent and complex medical syndrome of multifactorial origin. It is estimated that about 2% to 4% of the general population is affected by a bipolar spectrum condition. Among clinical samples of depressed patients, the estimated percentage of persons who screen positive for BD is about 10% to 35%.1-3 The longitudinal course of BD is characterized by a low rate of recovery, a high rate of recurrence, and poor interepisodic functioning.4 The standardized all-cause mortality ratio among patients with BD is increased approximately 2-fold.5 Actuarial estimates currently regard BD as possibly the most costly category of mental disorders in the United States.6

The foregoing clinical portrait of BD has only an evanescent similarity to the notions of vecordia and manic-depression, which were articulated by Kahlbaum and Kraepelin, respectively. These and other investigators diagnosed and categorized cyclical mood disorders (ie, BD) primarily on the basis of a favorable symptomatic and functional outcome and the absence of a "dementing" course.7

Results from several recently published longitudinal prospective studies have provided a more refined composite of BD. The symptomatic structure of BD is composed largely of subsyndrome depressive and anxious symptoms that rapidly shift in polarity and severity. For most persons affected, the symptoms of BD pursue an inexorably unremitting course that is accompanied by a progressive increase in vulnerability to recurrence, neurocognitive impairment, and psychosocial dysfunction.

Mortality studies have documented an increase in all-cause mortality in patients with BD. A newly established and rapidly growing database indicates that mortality due to chronic medical disorders (eg, cardiovascular disease) is the single largest cause of premature and excess deaths in BD.5 The standardized mortality ratio from suicide in BD is estimated to be approximately 18 to 25, further emphasizing the lethality of the disorder.

This description of BD points to the need to invoke a chronic disease management model (CDMM) when treating individuals with BD. A CDMM is encouraged for any syndrome, disorder, or disease characterized by multifaceted illness presentation, psychosocial burden, and chronic course. This model of health care delivery emphasizes a multidisciplinary systems-based approach with interventions at macro- (ie, health care system), meso- (ie, clinic structure) and micro- (ie, patient) levels.

Most clinicians are able to immediately intervene at the micro-level on a daily basis. Defining critical end points (ie, symptomatic remission) and using evidence-based guidelines to inform patients making treatment decisions are the guiding principles of a CDMM. Clearly, quantifying and objectifying patient outcomes with symptom measurement tools hitherto has not been common practice in BD management, let alone in the field of psychiatry.8

The encompassing aim in managing a patient with BD is to help him or her achieve wellness. Wellness has been defined and operationalized along 3 dimensions: symptoms, functioning, and pathophysiologic change.9 For many chronic medical disorders in which the pathophysiology has been elucidated (eg, coronary artery disease, diabetes mellitus), the availability of biomarkers has served multiple purposes, including quantification of illness...