title: Rheumatoid arthritis and the risk of bipolar disorder: a nationwide population-based study.
abstract: BACKGROUND
  Studies have suggested that chronic inflammation plays an essential role in the pathophysiology of both rheumatoid arthritis (RA) and bipolar disorder. The most common clinical features associated with RA are anxiety and depression. The risk of bipolar disorder among patients with RA has not been characterized adequately.
  
  
  OBJECTIVE
  To determine the association between RA and the subsequent development of bipolar disorder and examine the risk factors for bipolar disorder among patients with RA.
  
  
  METHODS
  We identified patients who were diagnosed with RA in the Taiwan National Health Insurance Research Database. A comparison cohort was created by matching patients without RA with those with RA according to age, sex, and comorbidities. The occurrence of bipolar disorder was evaluated in both cohorts.
  
  
  RESULTS
  The RA cohort consisted of 2,570 patients, and the comparison cohort consisted of 2,570 matched control patients without RA. The incidence of bipolar disorder (incidence rate ratio  = 2.13, 95% confidence interval [CI]  = 1.12-4.24, P =  .013) was higher among patients with RA than among control patients. Multivariate, matched regression models revealed that asthma (hazard ratio [HR]  = 2.76, 95% CI 1.27-5.96, P =  .010), liver cirrhosis (HR  = 3.81, 95% CI  = 1.04-14.02, P =  .044), and alcohol use disorders (HR  = 5.29, 95% CI  = 1.71-16.37, P =  .004) were independent risk factors for the development of bipolar disorder among patients with RA.
  
  
  CONCLUSIONS
  RA might increase the incidence of bipolar disorder development. Based on our data, we suggest that, following RA diagnosis, greater attention be focused on women with asthma, liver cirrhosis, and alcohol use disorder. Prospective clinical studies of the relationship between RA and bipolar disorder are warranted.
authors.affiliation: Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Chih-Chao
authors.initials: CC
authors.lastname: Hsu
authors.affiliation: Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: San-Chi
authors.initials: SC
authors.lastname: Chen
authors.affiliation: Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health & School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Liu
authors.affiliation: Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
authors.forename: Ti
authors.initials: T
authors.lastname: Lu
authors.affiliation: Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan.
authors.forename: Cheng-Che
authors.initials: CC
authors.lastname: Shen
authors.affiliation: Institute of Public Health & School of Medicine, National Yang-Ming University, Taipei, Taiwan; Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Yu-Wen
authors.initials: YW
authors.lastname: Hu
authors.affiliation: Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Chiu-Mei
authors.initials: CM
authors.lastname: Yeh
authors.affiliation: Department of Psychiatry, Yuanshan Branch, Taipei Veterans General Hospital, Yilan, Taiwan.
authors.forename: Pan-Ming
authors.initials: PM
authors.lastname: Chen
authors.affiliation: Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Tzeng-Ji
authors.initials: TJ
authors.lastname: Chen
authors.affiliation: Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Public Health & School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Li-Yu
authors.initials: LY
authors.lastname: Hu
mesh_terms: D000328:Adult; D001172:Arthritis, Rheumatoid / Q000150:complications*; D001714:Bipolar Disorder / Q000453:epidemiology* / Q000209:etiology*; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D012189:Retrospective Studies; D012306:Risk; D013624:Taiwan / Q000453:epidemiology