Question: How many patients with active Cushing’s have bipolar disorder? Also, are psychotic symptoms very common? 

Answer: This is great question. I will start by including short definitions of bipolar illness and psychosis. According to the National Institute of Mental Health (NIMH), “Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.’ This disorder involves clear changes in mood, energy, and activity levels, ranging from ‘periods of extremely “up,” elated, and energized behavior (known as manic episodes) to very sad, “down,” or hopeless periods (known as depressive episodes).’

‘Psychosis’ describes conditions where there has been some loss of contact with reality. According to the NIMH, ‘During a period of psychosis, a person’s thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not. Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech, and behavior that is inappropriate for the situation. A person in a psychotic episode may also experience depression, anxiety, sleep problems, social withdrawal, lack of motivation, and difficulty functioning overall.’ Psychotic episodes can occur in a person who is bipolar, or they can occur in association with other conditions including schizophrenia.

It is well known that Cushing’s is associated with mood changes, usually depression and/or anxiety. Unfortunately there are no studies showing the frequency of bipolar illness in people with Cushing’s. A few case reports describe the co-existence of these two conditions. Two cases describe Cushing’s presenting as bipolar illness (Tsai et. al., Psychiatry Clin Neurosci, 2016 Jan;70(1):71 and Ummar et al., Indian J Psychiatry, 2015 Apr-Jun;57(2):200-2). Another case describes Cushing’s exacerbating a bipolar condition (Ghadirian et al., Compr Psychiatry, 2005 Mar-Apr; 46(2):155-8).

I have noticed that a number of my Cushing’s patients also carry a diagnosis of bipolar illness, but whether there is a clear association between the two conditions is not known. It is also not clear if the signs and symptoms that are labeled as due to ‘bipolar’ are in fact part of Cushing’s symptomatology, or if these patients have a true diagnosis of bipolar, since elevated cortisol is known to cause mood lability, irritability, and sleep and energy changes — all findings that could also be seen in someone with bipolar. Another important question is the extent to which the bipolar symptoms might improve or resolve once Cushing’s is treated. Clearly this is an area that needs more research. I recommend that Cushing’s patients who may have symptoms that could suggest a bipolar diagnosis have a comprehensive psychiatric evaluation, and anticipate the possibility that their psychiatric medications may need to be adjusted after Cushing’s treatment.

By Dr. Eliza Geer, Medical Director of the Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center , New York City, NY, Spring, 2017