Economic benefit analysis of lithium battery recycling based on machine learning algorithm.

Lithium batteries, as an important energy storage device, are widely used in the fields of renewable vehicles and renewable energy. The related lithium battery recycling industry has also ushered in a golden period of development. However, the high cost of lithium battery recycling makes it difficult to accurately evaluate its recycling value, which seriously restricts the development of the industry. To address the above issues, machine learning will be applied in the field of economic benefit analysis for lithium battery recycling, and backpropagation neural networks will be combined with stepwise regression. On the basis of considering social and commercial values, a lithium battery recycling and utilization economic benefit analysis model based on stepwise regression backpropagation neural network was designed. The experimental results show that the mean square error of the model converges between 10-6 and 10-7, and the convergence speed is improved by 33%. In addition, in practical experiments, the model predicted the actual economic benefits of recycling a batch of lithium batteries. The results show that the predictions are basically in line with the true values. Therefore, the economic benefit analysis and prediction model for lithium battery recycling proposed in the study has the advantages of high accuracy and fast operation speed, providing new ideas and tools for promoting innovation in the field of economic benefit analysis. It has certain application potential in the evaluation of the benefits of lithium battery recycling.

Battery-Powered Portable Rotary Real-Time Fluorescent qPCR with Low Energy Consumption, Low Cost, and High Throughput.

The traditional qPCR instrument is bulky, expensive, and inconvenient to carry, so we report a portable rotary real-time fluorescent PCR (polymerase chain reaction) that completes the PCR amplification of DNA in the field, and the reaction can be observed in real-time. Through the analysis of a target gene, namely pGEM-3Zf (+), the gradient amplification and melting curves are compared to commercial devices. The results confirm the stability of our device. This is the first use of a mechanical rotary structure to achieve gradient amplification curves and melting curves comparable to commercial instruments. The average power consumption of our system is about 7.6 W, which is the lowest energy consumption for real-time fluorescence quantification in shunting PCR and enables the use of our device in the field thanks to its self-contained power supply based on a lithium battery. In addition, all of the equipment costs only about 710 dollars, which is far lower than the cost of a commercial PCR instrument because the control system through mechanical displacement replaces the traditional TEC (thermoelectric cooler) temperature control. Moreover, the equipment has a low technical barrier, which can suit the needs of non-professional settings, with strong repeatability.

Energy self-sufficient households with photovoltaics and electric vehicles are feasible in temperate climate.

The idea that households produce and consume their own energy, that is, energy self-sufficiency at a very local level, captures the popular imagination and commands political support across parts of Europe. This paper investigates the technical and economic feasibility of household energy self-sufficiency in Switzerland, which can be seen as representative for other regions with a temperate climate, by 2050. We compare sixteen cases that vary across four dimensions: household type, building type, electricity demand reduction, and passenger vehicle use patterns. We assume that photovoltaic (PV) electricity supplies all energy, which implies a complete shift away from fossil fuel based heating and internal combustion engine vehicles. Two energy storage technologies are considered: short-term storage in lithium-ion batteries and long-term storage with hydrogen, requiring an electrolyzer, storage tank, and a fuel cell for electricity conversion. We examine technological feasibility and total system costs for self-sufficient households compared to base cases that rely on fossil fuels and the existing power grid. PV efficiency and available rooftop/facade area are most critical with respect to the overall energy balance. Single-family dwellings with profound electricity demand reduction and urban mobility patterns achieve self-sufficiency most easily. Multi-family buildings with conventional electricity demand and rural mobility patterns can only be self-sufficient if PV efficiency increases, and all of the roof plus most of the facade can be covered with PV. All self-sufficient cases are technically feasible but more expensive than fully electrified grid-connected cases. Self-sufficiency may even become cost-competitive in some cases depending on storage and fossil fuel prices. Thus, if political measures improve their financial attractiveness or individuals decide to shoulder the necessary investments, self-sufficient buildings may start to become increasingly prevalent.

Safety monitoring of treatment in bipolar disorder in a tertiary care setting in Sri Lanka and recommendations for improved monitoring in resource limited settings.

BACKGROUND: Safety monitoring of medicines is essential during therapy for bipolar disorder (BD). We determined the extent of safety monitoring performed according to the International Society for Bipolar Disorders (ISBD) guidelines in patients with BD attending the main tertiary care psychiatry clinics in Sri Lanka to give realistic recommendations for safety monitoring in resource limited settings. METHODS: Patients diagnosed with BD on mood stabilizer medications for more than 1 year were recruited. Data were collected retrospectively from clinic and patient held records and compared with the standards of care recommended by ISBD guidelines for safety monitoring of medicines. RESULTS: Out of 256 patients diagnosed with BD, 164 (64.1%) were on lithium. Only 75 (45.7%) had serum lithium measurements done in the past 6 months and 96 (58.5%) had concentrations recorded at least once in the past year. Blood urea or creatinine was measured in the last 6 months only in 30 (18.3%). Serum electrolytes and thyroid-stimulating hormone (TSH) concentrations were measured in the last year only in 34 (20.7%) and 30 (18.3%) respectively. Calcium concentrations were not recorded in any patient. None of the patients on sodium valproate (n = 119) or carbamazepine (n = 6) had blood levels recorded to establish therapeutic concentrations. Atypical antipsychotics were prescribed for 151 (59%), but only 13 (8.6%) had lipid profiles and only 31 (20.5%) had blood glucose concentration measured annually. Comorbidities experienced by patients influenced monitoring more than the medicines used. Patients with diabetes, hypothyroidism and hypercholesterolemia were more likely to get monitored for fasting blood glucose and (p < 0.001), TSH (p < 0.001) and lipid profiles (p < 0.001). Lithium therapy was associated with TSH monitoring (p < 0.05). Therapy with atypical antipsychotics was not associated with fasting blood glucose or lipid profile monitoring (p > 0.05). A limitation of the study is that although some tests were performed, the results may not have been recorded. CONCLUSIONS: Safety monitoring in BD was suboptimal compared to the ISBD guidelines. ISBD standards are difficult to achieve in resource limited settings due to a multitude of reasons. Realistic monitoring benchmarks and recommendations are proposed for methods to improve monitoring in resource limited settings based on our experience.

Study protocol for a randomised pragmatic trial comparing the clinical and cost effectiveness of lithium and quetiapine augmentation in treatment resistant depression (the LQD study).

BACKGROUND: Approximately 30-50% of patients with major depressive disorder can be classed as treatment resistant, widely defined as a failure to respond to two or more adequate trials of antidepressants in the current episode. Treatment resistant depression is associated with a poorer prognosis and higher mortality rates. One treatment option is to augment an existing antidepressant with a second agent. Lithium and the atypical antipsychotic quetiapine are two such add-on therapies and are currently recommended as first line options for treatment resistant depression. However, whilst neither treatment has been established as superior to the other in short-term studies, they have yet to be compared head-to-head in longer term studies, or with a superiority design in this patient group. METHODS: The Lithium versus Quetiapine in Depression (LQD) study is a parallel group, multi-centre, pragmatic, open-label, patient randomised clinical trial designed to address this gap in knowledge. The study will compare the clinical and cost effectiveness of the decision to prescribe lithium or quetiapine add-on therapy to antidepressant medication for patients with treatment resistant depression. Patients will be randomised 1:1 and followed up over 12 months, with the hypothesis being that quetiapine will be superior to lithium. The primary outcomes will be: (1) time to all-cause treatment discontinuation over one year, and (2) self-rated depression symptoms rated weekly for one year via the Quick Inventory of Depressive Symptomatology. Other outcomes will include between group differences in response and remission rates, quality of life, social functioning, cost-effectiveness and the frequency of serious adverse events and side effects. DISCUSSION: The trial aims to help shape the treatment pathway for patients with treatment resistant depression, by determining whether the decision to prescribe quetiapine is superior to lithium. Strengths of the study include its pragmatic superiority design, broad inclusion criteria (external validity) and longer follow up than previous studies. TRIAL REGISTRATION: ISRCTN registry: ISRCTN16387615 , registered 28 February 2016. ClinicalTrials.gov: NCT03004521 , registered 17 November 2016.

Lithium or an atypical antipsychotic drug in the management of treatment-resistant depression: a systematic review and economic evaluation.

BACKGROUND: Patients with treatment-resistant depression (TRD) are those with major depressive disorder that has not responded adequately to treatment. The causes of depression are not fully understood, although there is evidence to suggest that depression is a complex interaction among biological, genetic, psychosocial and environmental factors. Strategies available for the treatment of patients with TRD include pharmacological, non-pharmacological, and psychological and psychosocial interventions. Pharmacological treatment options include switching to a different antidepressant, the addition of another antidepressant of a different class, or use of an augmenting agent, such as anticonvulsants, lithium or atypical antipsychotics (AAPs). However, there is limited evidence available on the effectiveness of these strategies in the treatment of TRD. OBJECTIVES: To estimate the clinical effectiveness and cost-effectiveness of augmentation of selective serotonin reuptake inhibitor (SSRI) antidepressant therapy with either lithium or an AAP drug in the management of people with treatment-resistant unipolar depression, defined as failure to respond to two or more antidepressant drugs in their current episode of depression. DATA SOURCES: Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, PsycINFO and NHS Economic Evaluation Database (NHS EED). All databases were searched from inception to August 2011. Additional data were obtained from manufacturers. REVIEW METHODS: Systematic reviews of studies evaluating clinical effectiveness, economic analyses and quality of life (QoL) were executed. Quality assessment according to predefined criteria was undertaken independently by two reviewers. Pairwise meta-analyses and mixed-treatment comparisons (MTCs) using both fixed- and random-effects models were undertaken based on intention-to-treat analyses. A probabilistic de novo mathematical model was developed to synthesise the available data on costs and clinical outcomes from the UK NHS perspective over a 1-year time horizon (8 weeks of acute treatment captured by a decision tree and 10 months of maintenance treatment captured by a Markov model). RESULTS: Twelve randomised controlled trials (RCTs) were identified in the review of clinical effectiveness literature; 10 considered SSRI + AAP compared with SSRI + placebo/no treatment, one considered SSRI + AAP compared with SSRI + lithium and one considered SSRI + lithium compared with SSRI + placebo. The RCTs included in the primary analyses used fluoxetine as the background SSRI and olanzapine as the AAP. Results of the MTC showed a non-significant trend in favour of lithium augmentation for response [lithium a priori odds ratio (OR) 1.29; 95% credible interval (CrI) 0.11 to 5.32; lithium post hoc OR 4.15; 95% CrI 0.25 to 20.34 (the trial informing the comparison with lithium reported response using two different definitions)], mean change in Montgomery-Åsberg Depression Rating Scale score from baseline (mean difference - 1.47, 95% CrI - 9.10 to 6.41) and all-cause withdrawals (OR 0.74, 95% CrI 0.10 to 2.66). Four economic evaluations (none directly addressing the review question) and 17 studies that reported on QoL were identified and summarised in narrative reviews. The results of the de novo modelling indicate that augmentation of SSRI with lithium dominates augmentation of an SSRI with AAP (i.e. it resulted in cost savings of £905 per person per year and generated more health benefits, estimated to be 0.03 quality-adjusted life-years). However, sensitivity analyses showed that the model was highly sensitive to changes in acute treatment efficacy (response and remission) or discontinuation. The model was not sensitive to changes in other parameters. LIMITATIONS: In patients with TRD, there is a lack of direct evidence comparing the clinical effectiveness of augmenting an SSRI with an AAP compared with augmenting with lithium. RCTs were identified which facilitated comparison of adding AAP with adding lithium via a MTC. However, variations in the definitions of response implemented in the RCTs, together with differences in patient baseline characteristics across RCTs, introduce bias into the analysis. The direction and extent of the bias is uncertain. CONCLUSIONS: Augmentation of SSRIs with lithium or AAP is likely to be beneficial in people with TRD. Clinical evaluation based on the limited evidence identified in this research indicates no statistically significant difference between the two augmentation strategies. Cost-effectiveness analyses suggest that augmentation with lithium is less expensive and more effective than augmentation with AAP. However, the uncertainty in the clinical estimates of discontinuation and treatment response is reflected in the model results. A RCT comparing the two augmentation strategies, reporting relevant outcomes, including QoL, is needed. STUDY REGISTRATION: PROSPERO CRD42011001464.

Sustainable governance of scarce metals: the case of lithium.

Minerals and metals are finite resources, and recent evidence suggests that for many, primary production is becoming more difficult and more expensive. Yet these resources are fundamentally important for society--they support many critical services like infrastructure, telecommunications and energy generation. A continued reliance on minerals and metals as service providers in modern society requires dedicated and concerted governance in relation to production, use, reuse and recycling. Lithium provides a good example to explore possible sustainable governance strategies. Lithium is a geochemically scarce metal (being found in a wide range of natural systems, but in low concentrations that are difficult to extract), yet recent studies suggest increasing future demand, particularly to supply the lithium in lithium-ion batteries, which are used in a wide variety of modern personal and commercial technologies. This paper explores interventions for sustainable governance and handling of lithium for two different supply and demand contexts: Australia as a net lithium producer and Switzerland as a net lithium consumer. It focuses particularly on possible nation-specific issues for sustainable governance in these two countries' contexts, and links these to the global lithium supply chain and demand scenarios. The article concludes that innovative business models, like 'servicizing' the lithium value chain, would hold sustainable governance advantages for both producer and consumer countries.

The management of individuals with bipolar disorder: a review of the evidence and its integration into clinical practice.

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify differences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps best bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder. Anticonvulsants, such as lamotrigine, have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when formulating recommendations for the management of bipolar disorder.

Effectiveness and medical costs of divalproex versus lithium in the treatment of bipolar disorder: results of a naturalistic clinical trial.

OBJECTIVE: The clinical, quality of life (QOL), and medical cost outcomes of treatment with divalproex were compared with lithium in patients with bipolar I disorder over 1 year. METHODS: In a pragmatic, randomized clinical trial, 201 adults hospitalized with bipolar I manic or mixed episodes were randomized to divalproex or lithium, in addition to usual psychiatric care, and followed for 1 year. All subsequent treatment of bipolar disorder was managed by the patient's psychiatrist. Symptoms of mania and depression were evaluated at baseline and at hospital discharge. Assessments at the start of maintenance therapy and after 1, 3, 6, 9 and 12 months included manic and depressive symptoms, disability days and QOL. Medical resource use data were also collected monthly and costs were estimated using national sources. RESULTS: Divalproex-treated patients (12%) were less likely to discontinue study medications for lack of efficacy or adverse effects than lithium-treated patients (23%). No statistically significant differences between the treatment groups were observed over the 1-year maintenance phase for clinical symptoms, QOL outcomes, or disability days. Mean estimated total medical costs were USD 28,911 for the divalproex group compared with USD 30,666 for the lithium treatment group. Patients continuing mood stabilizer therapy at 3 months had slightly better health outcomes and substantially lower total medical costs than those who discontinued therapy ( USD 10,091 versus USD 34,432, respectively). CONCLUSIONS: Divalproex maintenance treatment for bipolar disorder resulted in comparable medical costs, clinical and QOL outcomes compared with lithium. Patients remaining on mood stabilizer therapy had substantially lower total medical costs and better health outcomes compared with those who discontinued therapy.

A rapid and systematic review and economic evaluation of the clinical and cost-effectiveness of newer drugs for treatment of mania associated with bipolar affective disorder.

OBJECTIVES: To evaluate the clinical and cost-effectiveness of quetiapine, olanzapine and valproate semisodium in the treatment of mania associated with bipolar disorder. DATA SOURCES: Electronic databases; industry submissions made to the National Institute for Clinical Excellence. REVIEW METHODS: Randomised trials and economic evaluations that evaluated the effectiveness of quetiapine, olanzapine or valproate semisodium in the treatment of mania associated with bipolar disorder were selected for inclusion. Data were extracted by one reviewer into a Microsoft Access database and checked for quality and accuracy by a second. The quality of the cost-effectiveness studies was assessed using a checklist updated from that developed by Drummond and colleagues. Relative risk and mean difference data were presented as Forest plots but only pooled where this made sense clinically and statistically. Studies were grouped by drug and, within each drug, by comparator used. Chi-squared tests of heterogeneity were performed for the outcomes if pooling was indicated. A probabilistic model was developed to estimate costs from the perspective of the NHS, and health outcomes in terms of response rate, based on an improvement of at least 50% in a patient's baseline manic symptoms derived from an interview-based mania assessment scale. The model evaluated the cost-effectiveness of the alternative drugs when used as part of treatment for the acute manic episode only. RESULTS: Eighteen randomised trials met the inclusion criteria. Aspects of three of the quetiapine studies were commercial-in-confidence. The quality of the included trials was limited and overall, key methodological criteria were not met in most trials. Quetiapine, olanzapine and valproate semisodium appear superior to placebo in reducing manic symptoms, but may cause side-effects. There appears to be little difference between these treatments and lithium in terms of effectiveness, but quetiapine is associated with somnolence and weight gain, whereas lithium is associated with tremor. Olanzapine as adjunct therapy to mood stabilisers may be more effective than placebo in reducing mania and improving global health, but it is associated with more dry mouth, somnolence, weight gain, increased appetite, tremor and speech disorder. There was little difference between these treatments and haloperidol in reducing mania, but haloperidol was associated with more extrapyramidal side-effects and negative implications for health-related quality of life. Intramuscular olanzapine and lorazepam were equally effective and safe in one very short (24 hour) trial. Valproate semisodium and carbamazepine were equally effective and safe in one small trial in children. Olanzapine may be more effective than valproate semisodium in reducing mania, but was associated with more dry mouth, increased appetite, oedema, somnolence, speech disorder, Parkinson-like symptoms and weight gain. Valproate semisodium was associated with more nausea than olanzapine. The results from the base-case analysis demonstrate that choice of optimal strategy is dependent on the maximum that the health service is prepared to pay per additional responder. For a figure of less than 7179 British pounds per additional responder, haloperidol is the optimal decision; for a spend in excess of this, it would be olanzapine. Under the most favourable scenario in relation to the costs of responders and non-responders beyond the 3-week period considered in the base-case analysis, the incremental cost-effectiveness ratio of olanzapine is reduced to 1236 British pounds. CONCLUSIONS: In comparison with placebo, quetiapine, olanzapine and valproate semisodium appear superior in reducing manic symptoms, but all drugs are associated with adverse events. In comparison with lithium, no significant differences were found between the three drugs in terms of effectiveness, and all were associated with adverse events. Several limitations of the cost-effectiveness analysis exist, which inevitably means that the results should be treated with some caution. There remains a need for well-conducted, randomised, double-blind head-to-head comparisons of drugs used in the treatment of mania associated with bipolar disorder and their cost-effectiveness. Participant demographic, diagnostic characteristics, the treatment of mania in children, the use of adjunctive therapy and long-term safety issues in the elderly population, and acute and long-term treatment are also subjects for further study.

How should findings on antisuicidal effects of lithium be integrated into practical treatment decisions?

Beyond its prophylactic efficacy lithium has demonstrated possibly specific antisuicidal effects. Lithium significantly reduces the high excess mortality of patients with affective disorders. Appropriate lithium prophylaxis prevents ca. 250 suicides per year in Germany although lithium salts are prescribed within the National Health Scheme at low frequency (0.06% of the population). Rational treatment strategies most likely would demand for about 10 times higher prescription rates. Guidelines and algorithms for selecting an appropriate prophylactic strategy in affective disorders should take into consideration the suicide risk of an individual patient.

[Prophylactic long-term therapy of affective disorders with lithium, valproic acid and carbamazepine--effectiveness and cost-effectiveness]. / Die prophylaktische Langzeitbehandlung affektiver Störungen mit Lithium, Valproat und Carbamazepin - Ein Uberblick zur Wirksamkeit und Kosteneffektivität -

Affective disorders have a substantial public health impact due to morbidity, mortality, quality of life impairment and economic implications. There has been renewed debate of the efficacy and effectiveness of Lithium in long-term treatment of affective disorders. In the present paper current literature is discussed with a focus on the routine use of Lithium (effectiveness) and on cost aspects. Recent reviews have confirmed the prophylactic efficacy of Lithium in bipolar affective disorders. However, there is some evidence that effectiveness studies do not hold what efficacy research would promise. Non-compliance is likely to be a major reason for this. Lithium response rates have declined in recent studies. This may be related to diagnostic change (broader concept of affective disorders) and more widespread Lithium use. Non-compliance in patients taking Lithium is a primary factor in relapse with substantial cost effects (due to inpatient care). Current studies compare Lithium with Valproic acid/divalproex, and find cost advantages for the latter possibly due to better compliance. A special suicide-preventive effect has only been proven for Lithium. To ensure the full prophylactic potential of Lithium compliance needs to be improved. Future studies will compare Lithium with Valproic acid/divalproex, Carbamazepine and new treatment strategies more detailed.

Lithium revisited: savings brought about by the use of lithium, 1970-1991.

BACKGROUND: Recent estimates of the cost of manic-depressive illness totaled roughly $45 billion in 1991. Using data from the Epidemiological Catchment Area (ECA) study, this study estimates the savings brought about by the use of lithium between 1970 and 1991. METHODS: Total savings are the difference between estimated actual costs and projected costs had lithium never been introduced. Actual yearly costs were interpolated from data for 1970 and 1991, and projected costs were obtained by adjusting 1970 costs with Consumer Price Index (CPI) and population inflaters. All costs for 1970 were obtained using methods almost identical to those used to calculate the 1991 costs of manic-depressive illness, presented in a previous publication. All savings are presented in 1991 dollars. RESULTS: Between 1970 and 1991, lithium saved over $170 billion, or roughly over $8 billion per year. Approximately $15 billion in direct costs, which included inpatient and outpatient care as well as research, was saved between 1970 and 1991. The savings are more dramatic for indirect costs, which include the lost productivity of wage-earners, homemakers, family caregivers, and individuals who are in institutions or who committed suicide; these totaled roughly $155 billion. CONCLUSIONS: Our results suggest that, although manic-depressive illness is still costly, lithium has been tremendously successful in treating the illness, and has provided enormous financial savings in the process.

Effects of divalproex versus lithium on length of hospital stay among patients with bipolar disorder.

The medical records of all inpatients with bipolar disorder at the Connecticut Mental Health Center in 1997 were examined to compare length of stay for patients who began monotherapy with divalproex (27 treatment starts) and lithium (20 treatment starts). No statistically significant difference was found in length of stay (11. 5+/-6.9 and 10.3+/-5.2 days for patients on divalproex and lithium, respectively) or other length-of-stay variables. Demographic variables, diagnostic variables, and dosages of neuroleptics and benzodiazepines used adjunctively were similar as well. Dosages and blood levels for divalproex and lithium were consistent with practice guidelines. Prospective randomized studies are needed to compare the cost-effectiveness of divalproex and of lithium in the treatment of bipolar disorder.

[Prophylactic treatment of mood disorders: cost effectiveness analysis comparing lithium and carbamazepine]. / Traitement préventif des troubles de l'humeur: comparaison coût-efficacité du lithium et de la carbamazépine.

Economic impact of lithium therapy has seldom been assessed, economic comparisons with alternative mood stabilizers are almost non existent. This economic evaluation of preventive treatment of mood disorders recurrences (whether unipolar or bipolar) compared lithium with carbamazepine, through data from a randomized controlled clinical trial. A retrospective analysis of medical files of index patients is included in this trial, with experts' global ratings. A brief survey checked for representativity of in-patients length of stay. The model compared two cohorts of patients followed-up for two years after prophylactic treatment had begun. Rates of recurrence and direct medical costs related to mood disorders (prophylactic treatment, treatment of recurrences and serious adverse effects) were assessed. Data extrapolation was necessary because of variable lengths of follow-up during the trial and was based on medical review of index patients. Assessment of consumed health care resources were derived from the available database of the clinical trial, when necessary practice guidelines and experts' opinions were added to the model. Costs were valued according to available french unit costs (Vidal, NGAP, and Comptes de la santé). Analysis only included direct costs. An estimate of mean cost of care of 15,404 French francs per year per patient was calculated. The components of health costs show that in-patient costs are the most important part of annual medical costs for mood disorders (70% of the total costs). Prophylactic medication costs accounted for only 6.9% of total costs. Comparison of prophylactic alternatives gave lithium a clinical benefit with 27% fewer recurrences than carbamazepine. Lithium led to an economic benefit of 4,280 French francs per year of treatment for a single patient. Robustness of this finding was assessed through a sensitivity analysis on estimate of length of stay. Total costs of treatment would be equal between lithium and carbamazepine if length of stay in hospital for lithium patients was increased by 51%. According to the cost-effectiveness analysis developed in this study, lithium should stay the "gold standard" of prophylactic treatment of recurrent mood disorders, and has both clinical and economic advantages compared to carbamazepine.

Pharmacoeconomic and health outcome comparison of lithium and divalproex in a VA geriatric nursing home population: influence of drug-related morbidity on total cost of treatment.

OBJECTIVE: Clinicians use mood stabilizers for treating agitation in older patients, but limited information is available regarding side effects and costs in clinical practice. Total costs of treatment were assessed for a subset of geriatric patients receiving either lithium carbonate or divalproex sodium for agitation. STUDY DESIGN: Retrospective cohort examination of the medical records of 72 patients, 55 years of age or older, in a Veterans Administration long-term, skilled nursing care facility, with a diagnosis of dementia or bipolar affective disorder or both. PATIENTS AND METHODS: Patients treated with lithium or divalproex during the previous 4 years (1994-1997) were evaluated. Quantitative information was collected and compared regarding routine care, including cost of treatment and laboratory monitoring; and occurrence of adverse events and associated diagnostic and treatment measurements. RESULTS: Routine care costs for the 2 groups were similar. The lower annual acquisition cost per patient-year for lithium ($15 vs $339 for divalproex) was offset by higher laboratory monitoring costs associated with its administration ($278 vs $53 for divalproex). Examining the adverse events showed that the lithium group had more medication-related adverse events (32 total) than the divalproex group (10 total) and more severe occurrences, including 6 cases requiring medical intensive care unit (MICU) hospitalization. The total mean cost of treating drug-related mild-to-moderate morbidity was $3472 for lithium and $672 for divalproex. An additional cost per admission of $12,910 ($77,462 for all 6 cases) increased total morbidity-related expenditures in the lithium group to $80,934. CONCLUSIONS: Treating geriatric patients with lithium requires careful monitoring because of side effects. Staffing and resource limitations of a skilled nursing care facility may compromise optimal lithium monitoring in elderly patients. The collected data indicated that divalproex does not result in as many as or as severe adverse events and is, therefore, a safer treatment. The use of lithium was not only more expensive (on average $2875 more per patient) than treatment with divalproex but, more importantly, it was associated with poorer patient outcomes.

The social and economic effects of manic depressive illness and of its treatment in lithium clinics.

Advising about the employment of those who have had manic depressive episodes requires Occupational Health Physicians to obtain, with consent, an objective account of previous episodes and to appreciate the enormous range of manic and depressive manifestations. Familiarity is needed with the likely effects of treatment of episodes and the benefits and problems of prophylaxis--not just in general but in individual cases, for example, where driving is required. This article summarizes research into the effects of lithium preparations on the course of the illness, thyroid and renal function and the risk of suicide. The author found that changing from treatment of episodes to continuous prophylaxis benefited employment and personal relationships without causing body weight problems. Many patients do well in life if supported by an experienced professional team, with 61% requiring no further admissions once on lithium, and with an 86% reduction in admissions achieved in our local clinic.