Maternal and child delivery charges, postpartum charges, and utilization of care among women with bipolar disorder: a cohort study.

Bipolar disorder (BD) during pregnancy is known to be a morbid condition associated with poor outcomes for both the mother and her infant. We aimed to determine if women with BD and their children have higher charges and health service utilization than mother-infant dyads with and without other mental health (MH) diagnoses. The International Classification of Diseases, Ninth Revision (ICD9) codes were used to identify mutually exclusive groups of women who gave birth between January 1, 2011, and December 31, 2012, coding first for BD, then diagnoses that comprised an "other MH diagnoses group" that included post-traumatic stress disorder, anxiety, and depression. Health service utilization and related charges were obtained for the dyad for delivery and for 2 years post-delivery at a single tertiary care center. Analyses included 4440 dyads. A BD diagnosis occurred in 1.8% of medical record codes, other MH diagnoses in 10%, and no known MH diagnosis in 88%. Compared with women with both other MH and no known MH diagnoses, women with BD had higher delivery charges (p < 0.001), higher cumulative charges in the 2 years postpartum (p < 0.001), higher preterm birth and low birthweight rates (15.5% v. 6.9% and 20.8% v. 6.4%, p < 0.001, BD v. no known MH, respectively), and greater utilization of inpatient and emergency psychiatric care services (p < 0.001). Compared with women with and without other mental health diagnoses, women with BD have the highest care utilization and charges. They also have higher preterm birth and low birthweight infant rates, two clinically relevant predictors of long-term health for the child. Given the low prevalence of BD and severity of the disease versus the magnitude of systems costs, women with BD, and their children, deserve the heightened attention afforded to other high-risk perinatal conditions.

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.

Electroconvulsive Treatment Utilization for the Inpatient Management of Severe Manic Episodes of Bipolar Disorder.

OBJECTIVE: Main objectives of the study are to (1) describe the utilization of electroconvulsive treatment (ECT) for the treatment of manic episodes (ME) and (2) examine the effect of early inpatient use of ECT (within 7 days of admission) compared with delayed use on length of stay and cost of inpatient care. METHOD: The total sample of 14,005 inpatients with a principal diagnosis of bipolar disorder, ME (2012-2014), from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project were analyzed using univariate and logistic regressions. This represented data from 4411 hospitals from 45 states in the United States. RESULTS: The rate of ECT use was higher in young adults (<50 years), female patients, and whites from high-income families. Electroconvulsive treatment was preferred more in private, nonprofit, urban, and teaching hospitals. The percentages of overall hospitals where ECT was administered for mania by region were as follows: 22% in the Northeast, 23% in Midwest. 17% in the South, and 10% in the West. Approximately half (55.3%) of patients received initial ECT session within the first 7 days (median) after admission. Early ECT was associated with significantly shorter (-14.7 days) and less costly (-$41,976) inpatient care per patient. CONCLUSIONS: Patients treated with ECT are generally sicker and more treatment resistant. However, ECT should not be considered only as a "last resort" in the treatment algorithm. Inpatient ECT for patients with MEs if initiated during the first 7 days of hospitalization reduces length of stay and cost.

Disparities in Health Coverage Across Gender and Marital Status among Discharged Psychiatric Patients.

The goal of this study was to examine the demographics sex and marital status of inpatients with schizophrenia and bipolar and compare differences in patients' chances of possessing adequate health coverage to cover hospital expenses. Data from the National Hospital Discharge Survey was extracted and analyzed. For hospital discharges of patients age 18 and older 702,626 hospital discharges were included in the study representing a weighted population of 77,082,738 hospital discharges. Prediction model was applied to test the ability of the independent variables sex and marital status to predict differences in health coverage in multinomial logistic regression (MLR) test. Results indicate that sex and marital status were significant predictors of health coverage type that patient owned. Male, unmarried and with unknown marital status patients were more likely to be either uninsured or publicly insured. Public health policy legislation efforts need to address public-health-insurance provisions that limit the coverage of treatment for psychiatric patients.

Comparative economic evaluation of quetiapine plus lamotrigine combination vs quetiapine monotherapy (and folic acid vs placebo) in patients with bipolar depression (CEQUEL).

OBJECTIVES: Although not licensed for acute bipolar depression, lamotrigine has evidence for efficacy in trials and its use is recommended in guidelines. So far there had been no prospective health economic evaluation of its use. METHODS: Cost-utility analysis of the CEQUEL trial comparing quetiapine plus lamotrigine vs quetiapine monotherapy (and folic acid vs placebo in an add-on factorial design) for patients with bipolar depression (n = 201) from the health and social care perspective. Differences in costs together with quality-adjusted life years (QALYs) between the groups were assessed over 52 weeks using a regression-based approach. RESULTS: Health-related quality of life improved substantially for all randomization groups during follow-up with no significant difference in QALYs between any of the comparisons (mean adjusted QALY difference: lamotrigine vs placebo -0.001 (95% CI: -0.05 to 0.05), folic acid vs placebo 0.002 (95% CI: -0.05 to 0.05)). While medication costs in the lamotrigine group were higher than in the placebo group (£647, P < 0.001), mental health community/outpatient costs were significantly lower (-£670, P < 0.001). Mean total costs were similar in the groups (-£180, P = 0.913). CONCLUSIONS: Lamotrigine improved clinical ratings in bipolar depression compared with placebo. This differential effect was not detected using the EQ-5D-3L. The additional cost of lamotrigine was balanced by significant savings in some other medical costs which made its use cost neutral to the health service. Compared to placebo, folic acid produced neither clinical nor significant health economic benefits. The study supports the use of lamotrigine in combination with other drugs to treat bipolar depression.

Out-of-pocket health expenditures in patients with bipolar disorder, anxiety, schizophrenia and other psychotic disorders: findings from a study in a psychiatry outpatient clinic in Turkey.

PURPOSE: The aim of this study is to explore the amount of OOP health expenditures and their determinants in patients with bipolar disorder, anxiety, schizophrenia and other psychotic disorders in a psychiatry outpatient clinic of Turkey. METHODS: The study group was 191 patients who attended to the Psychiatry Outpatient Clinic in June 2014. All patients were previously diagnosed with either 'bipolar disorder', 'anxiety disorder' or 'schizophrenia and other psychotic disorders'. The dependent variable was OOP expenditures for prescription, medical tests and examinations. Independent variables were age, gender, education, occupation, existence of social and/or private health insurance, equivalent household income and the financial resources. Student's t test, Mann-Whitney U test, ANOVA and logistic regression methods were applied with SPSS 15.0 for analysis. RESULTS: OOP expenditures per admission were higher in patients with schizophrenia and other psychotic disorders ($8.4) than those with anxiety disorders ($4.8) (p = 0.02). OOP expenditures were higher in patients paying with debit ($9.8) than paying with monthly income ($6.2) (p = 0.04). OOP expenditures were higher in patients without social health insurance ($45.8) than others ($4.8) (p = 0.003). There was not a difference in OOP expenditures with respect to equivalent household income level, occupational class or education level of the patients (respectively p: 0.90, p: 0.09, p: 0.52). CONCLUSIONS: Patients who were diagnosed with 'schizophrenia and other psychotic disorders' were disadvantaged in paying significantly higher amounts for their treatment. A substantial group of these patients compulsorily payed with debit. Considering this financial burden, diagnosis of the patient should be prioritized in health insurance coverage.

Financial difficulties in bipolar disorder part 1: longitudinal relationships with mental health.

BACKGROUND: There has been little research on whether finances affect mental health in bipolar disorder. AIMS: This study aimed to examine the relationship between finances and mental health in bipolar disorder across two time points. METHODS: Fifty-four participants with bipolar disorder in a National Health Service community mental health service completed questionnaires examining financial difficulties, compulsive buying and perceived financial well-being. Questionnaires also measured alcohol dependence, stress, depression, anxiety, past and current manic symptoms. RESULTS: Partial correlations showed correlations over time: depression, anxiety and stress predicted later compulsive buying. Compulsive buying also predicted later anxiety. Lower perceived financial wellness increased anxiety and stress over time. Being on benefits was associated with higher depression and going without items such as clothes was linked to higher depression, stress, anxiety and past hypomanic symptoms. CONCLUSIONS: Financial difficulties are related to mental health in bipolar disorder. Poor mental health leads to compulsive buying, whereas worry about finances increases anxiety and stress, with a vicious cycle for anxiety.

Predictors of long-term work disability among patients with type I and II bipolar disorder: a prospective 18-month follow-up study.

OBJECTIVES: Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, vocational ability and predictors of long-term work disability have rarely been studied among patients with BD. We investigated clinical predictors of work disability among patients with BD in psychiatric care. METHODS: The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (N = 191) representing adult (18-59 years) psychiatric inpatients and outpatients with DSM-IV bipolar I disorder (BD-I) and bipolar II disorder (BD-II) in three Finnish cities. Within the JoBS, we investigated the prevalence of disability pensions at baseline, and predictors for being granted a disability pension during an 18-month follow-up of the 151 patients in the labor force at baseline. Cox models were used to determine predictors for onset of disability pension. RESULTS: At baseline, 21% (40/191) of the patients already had a disability pension. During the follow-up, a further 38 patients (25% of the 151 followed) were granted a new disability pension. The predictors included older age, male gender, depressive index episode, higher number of psychiatric hospitalizations, generalized anxiety disorder, avoidant personality disorder, and depressive burden during follow-up. However, the predictors differed depending on bipolar subtype, age, and gender. CONCLUSIONS: BD-I and BD-II are associated with a major risk of long-term work disability, the proportion of patients with a disability pension rising to 41% in the medium-term follow-up of the Finnish cohort investigated in the present study. Severe clinical course, depression, comorbidities, age, and gender are likely to be the main predictors but predictors may vary depending on the subgroup.

Cost of illness for bipolar disorder: a systematic review of the economic burden.

OBJECTIVES: Recent reviews lack important information on the high cost-of-illness worldwide for bipolar disorder (BD). Therefore, the present study systematically analyzed those costs, their driving components, and the methodological quality with which the few existing cost-of-illness investigations have been performed. METHODS: In June 2012, we conducted a systematic literature review of electronic databases to identify relevant cost-of-illness studies published since 2000. Their methodological quality was assessed. Costs were standardized by first extrapolating them to 2009 using country-specific gross domestic product inflators and then converting them into US dollars via purchasing power parities (PPP). RESULTS: The main characteristics of 22 studies were evaluated. Ignoring outliers, costs per capita ranged from 8,000 to 14,000 US$-PPP for overall direct healthcare, from 4,000 to 5,000 US$-PPP for direct mental healthcare, and from 2,500 to 5,000 US$-PPP for direct BD-related care. Indirect costs ranged from 2,000 to 11,000 US$-PPP. Inpatient care was the main cost driver in three studies; drug costs, in two studies. Methodological quality was deemed satisfactory. CONCLUSIONS: The cost variance was great between studies. This was likely due to differences in methodology rather than healthcare systems, thereby making such comparisons difficult. The results showed that BD has a substantial economic burden on society. To gain more evidence, international standardized checklists are needed when undertaking cost-of-illness studies.

Economic evaluations in bipolar disorder: a systematic review and critical appraisal.

BACKGROUND: Bipolar disorder (BD) is a chronic illness and is one of the worldwide leading causes of disability. It is often a lifelong illness and incurs a substantial economic burden on the health care system, the patients, and society as a whole. However, there are few studies evaluating the economic impact of alternative strategies in the management of BD. OBJECTIVES: We reviewed and critically appraised the available published economic evidence on BD management. In addition, we explored advantages and disadvantages of different methods used in the economic evaluation of the management of BD. METHODS: A systematic literature search was undertaken using seven electronic databases to identify all English language articles published between January 1980 and March 2012 that provided data on complete economic evaluations for any treatment strategy for BD. The quality of included studies was appraised according to recommendations from the Cochrane Collaboration. RESULTS: A total of 7,284 citations were obtained. After initial screening, 20 eligible studies were identified, five of which were trial-based, and 15 of which were model-based economic evaluations. Given the variability in methods and the quality of the identified studies, no conclusive recommendation for the most cost-effective therapy for BD could be provided. CONCLUSIONS: The cost-effectiveness of different treatment strategies varied between settings, and transferability of these results across settings remains questionable. Although additional research using a longer time horizon is required to validate the findings for trial-based economic evaluations, discrete event simulation appears to be the most natural and plausible technique for modeling the cost-effectiveness of alternative BD treatment strategies.

Pharmaco-utilisation and related costs of drugs used to treat schizophrenia and bipolar disorder in Italy: the IBIS study.

BACKGROUND: Schizophrenia and bipolar disorder (BD) are psychiatric diseases that are commonly managed with antipsychotics. Treatment pathways are highly variable and no universal treatment guidelines are available. The primary objective of the Italian Burden of Illness in Schizophrenia and BD (IBIS) study was to describe pharmaco-utilisation of antipsychotic treatments and characteristics of patients affected by schizophrenia or BD. A secondary objective was to describe costs of illness for patients with schizophrenia or BD. METHODS: IBIS was a multicentre, real-world, retrospective, observational cohort study based on data obtained from administrative databases of 16 Local Health Units in Italy (~7.5 million individuals). Patients with schizophrenia or BD ≥18 years of age treated with antipsychotics between 1 January 2008 and 31 December 2009 were included in the primary analysis. Pharmaco-utilisation data were gathered over a follow-up period of 12 months. RESULTS: Patients with schizophrenia and BD received a wide variety of antipsychotic medications. The proportion of patients on antipsychotic monotherapy was 68% in patients with schizophrenia and 70% in patients with BD. In patients with schizophrenia, ~1/3 of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants (34.7%) compared with over half of those on antipsychotic polytherapy (52.2%). In patients with BD, use of mood stabilisers and/or antidepressants was even higher; 76.9% of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants compared with 85.5% of patients on antipsychotic polytherapy. Switch therapy was more frequent in patients with BD than in patients with schizophrenia, whereas add-on therapy was more frequent in patients with schizophrenia than in patients with BD. The mean total disease-related cost per patient per annum was higher in patients with schizophrenia (€4,157) than in patients with BD (€3,301). The number and cost of hospitalisations was higher in patients with BD, whereas the number and cost of nursing home stays was higher in patients with schizophrenia. CONCLUSION: Use of administrative databases has permitted retrieval of comprehensive information about therapeutic pathways, diagnostic history and costs in patients affected by schizophrenia or BD. A need for personalised treatment pathways has been described. TRIAL REGISTRATION: clinicaltrials.gov: NCT01392482 ; first received June 29, 2011.

Cost analysis of the adverse reactions of bipolar disorder treatment with aripiprazole and olanzapine in Spain.

OBJECTIVE: This study investigates the healthcare costs of adverse events (AE) associated with treatment of bipolar disorder with two atypical oral antipsychotics (AOA): aripiprazole (ARI) and olanzapine (OLA). METHODS: A cost analysis using a Markov model considering the following health states was performed: no existence of adverse events (NAE); extrapyramidal symptoms (EPS); weight gain (WG); and sexual dysfunction (SD). Transition probabilities amongst health states were estimated from meta-analyses of clinical trials and from a retrospective Spanish study. The healthcare costs associated to each health state were obtained from a published Spanish study. The minimum acquisition cost per mg of the mean daily dose for each AOA was used. This is considered to be a relevant efficiency criterion in Hospital Pharmacy Departments. The time horizon applied in the analysis was 12 months. A probabilistic sensitivity analysis was performed for all the variables involved in the analysis with Monte Carlo simulations. All costs were updated to 2013 costs using the Spanish Health System price index. RESULTS: In comparison with OLA, treatment with ARI generates annual average cost savings per patient of ¤289 (CI95% ¤271; ¤308). In the hypothetical scenario in which we assume that ARI may have a similar rate of sexual dysfunction as that of quetiapine (i.e. the lowest rate amongst AOAs), the additional cost per patient would be ¤323 (CI95% ¤330; ¤317). CONCLUSION: The results of this analysis show that patients treated with aripiprazole demonstrate lower adverse events costs in comparison to olanzapine. This difference may generate significant cost savings in the Spanish health system in the treatment of patients affected by bipolar disorders. The robustness of the results was tested via a probabilistic analysis.

Cost-utility analysis of adjunct repetitive transcranial magnetic stimulation for treatment resistant bipolar depression.

OBJECTIVE: To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) as an adjunct to standard care from an Australian health sector perspective, compared to standard care alone for adults with treatment-resistant bipolar depression (TRBD). METHODS: An economic model was developed to estimate the cost per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained for rTMS added to standard care compared to standard care alone, for adults with TRBD. The model simulated the time in three health states (mania, depression, residual) over one year. Response to rTMS was sourced from a meta-analysis, converted to a relative risk and used to modify the time in the depressed state. Uncertainty and sensitivity tested the robustness of results. RESULTS: Base-case incremental cost-effectiveness ratios (ICERs) were $72,299 per DALY averted (95 % Uncertainty Interval (UI): $60,915 to $86,668) and $46,623 per QALY gained (95 % UI: $39,676 - $55,161). At a willingness to pay (WTP) threshold of $96,000 per DALY averted, the base-case had a 100 % probability of being marginally cost-effective. At a WTP threshold of $64,000 per QALY gained, the base-case had a 100 % probability of being cost-effective. Sensitivity analyses decreasing the number of sessions provided, increasing the disability weight or the time spent in the depression state for standard care improved the ICERs for rTMS. CONCLUSIONS: Dependent on the outcome measure utilised and assumptions, rTMS would be considered a very cost-effective or marginally cost-effective adjunct to standard care for TRBD compared to standard care alone.

Matched Comparison Examining the Effect of Obesity on Clinical, Economic, and Humanistic Outcomes in Patients with Bipolar I Disorder.

INTRODUCTION: Bipolar I disorder (BD-I) is associated with an increased risk of obesity, but few studies have evaluated the real-world clinical, humanistic, and economic effects associated with obesity in people with BD-I. METHODS: This was a retrospective, cross-sectional analysis of responses to the 2016 and 2020 National Health and Wellness surveys. Respondents (18-64 years) with a self-reported physician diagnosis of BD-I were matched to controls without BD-I based on demographic and health characteristics. Respondents were categorized by body mass index as underweight/normal weight (< 25 kg/m2), overweight (25 to < 30 kg/m2), or obese (≥ 30 kg/m2). Multivariable regression models were used to compare obesity-related comorbidities, healthcare resource utilization (HCRU), health-related quality of life (HRQoL), work productivity, and indirect and direct costs. RESULTS: Before matching, the BD-I cohort was younger than the non-BD-I cohort and included more female and white respondents and a greater proportion covered by Medicaid or Medicare. After matching, the BD-I and non-BD-I cohorts had similar characteristics. A total of 5418 respondents (BD-I, n = 1806; matched controls, n = 3612) were analyzed. Obese respondents with BD-I reported the highest adjusted prevalences of high blood pressure (50%), high cholesterol (35%), sleep apnea (27%), osteoarthritis (17%), type 2 diabetes (12%), and liver disease (4%). Obesity in respondents with BD-I was associated with the lowest HRQoL scores. Measures of work impairment were highest in respondents with BD-I and obesity, as was HCRU. Respondents with BD-I and obesity had the highest associated total indirect and direct medical costs ($25,849 and $44,482, respectively). CONCLUSION: Obese respondents with BD-I had greater frequencies of obesity-related comorbidities, higher HCRU, lower HRQoL, greater work impairments, and higher indirect and direct medical costs. These findings highlight the real-world burden of obesity in people with BD-I and the importance of considering treatments that may reduce this burden.

Bipolar I disorder (or BD-I) is a serious mental illness that is associated with an increased risk of obesity. Only a few studies have looked at the real-world effects of obesity in people living with BD-I. We used responses from the 2016 and 2020 National Health and Wellness surveys to look at these real-world effects. We matched survey respondents so that those with BD-I had similar characteristics to those without BD-I. We also categorized the respondents by body mass index (underweight/normal weight, overweight, or obese). Then, we compared them across different outcomes. These effects were obesity-related medical conditions, quality-of-life measures, and different types of costs. We found that obese respondents with BD-I had the highest frequencies of high blood pressure, high cholesterol, sleep apnea (a condition where breathing stops while sleeping), osteoarthritis (a condition where joint tissues, such as in the knee or hip, break down over time), type 2 diabetes, and liver disease, along with the lowest scores for health-related quality of life. Obese respondents with BD-I had the highest work impairment scores, and the highest numbers of hospital visits, emergency department visits, and doctor visits in the 6 months before the survey. Finally, obese respondents with BD-I had the highest total costs related to work impairment and to medical care. This study reports the real-world effects of obesity in people living with BD-I. It is important to consider treatments for BD-I that may reduce these unfavorable effects.

Cross-sectional analysis of pharmaceutical industry payments to authors of clinical practice guidelines for bipolar disorder and major depressive disorder in Japan.

OBJECTIVE: Clinical practice guidelines (CPGs) are essential for standardising patient care based on evidence-based medicine. However, the presence of financial conflicts of interest (COIs) among CPG authors can undermine their credibility. This study aimed to examine the extent and size of COIs among authors of psychiatry CPGs in Japan. METHODS: This cross-sectional analysis of disclosed payments from pharmaceutical companies assesses the prevalence and magnitude of personal payments for lecturing, consulting and writing to CPGs for bipolar disorder and major depressive disorder in Japan between 2016 and 2020. RESULTS: This study found that 93.3% of authors received payments over a 5-year period, with total payments exceeding US$4 million. The median payment per author was US$51 403 (IQR: US$9982-US$111 567), with a notable concentration of payments among a small number of authors, including the CPG chairperson. Despite these extensive financial relationships, only a fraction of authors disclosed their COIs in the CPGs. These large amounts of personal payments were made by pharmaceutical companies manufacturing new antidepressants and sleeping aids listed in the CPGs. CONCLUSIONS: This study found that more than 93% of authors of CPGs for major depressive disorder and bipolar disorder in Japan received considerable amounts of personal payments from the pharmaceutical industry. The findings highlight deviations from international COI management standards and suggest a need for more stringent COI policies for psychiatry CPGs in Japan.

Clinical management and burden of bipolar disorder: results from a multinational longitudinal study (WAVE-bd).

Bipolar disorder is a mood disorder which requires complex treatment. Current treatment guidelines are based on the results of published randomized clinical trials and meta-analyses which may not accurately reflect everyday clinical practice. This multi-national, multi-centre, observational cohort study describes clinical management and clinical outcomes related to bipolar disorder in real-life settings, assesses between-country variability and identifies factors associated with clinical outcomes. Adults from 10 countries in Europe and South America who experienced at least one mood episode in the preceding 12 months were included. Overall, 2896 patients were included in the analyses and followed for at least 9 months across a retrospective and prospective study phase. Main outcome measures were the number and incidence rate of mood episodes (relapses and recurrences) and healthcare resource use including pharmacological treatments. Relapses and recurrences were reported in 18.2 and 40.5% of patients, respectively; however, the reported incidence rate of relapses was higher than that of recurrences [1.562 per person-year (95% CI 1.465-1.664) vs. 0.691 per person-year (95% CI 0.657-0.726)]. Medication use was high during all episode types and euthymia; the percentage of patients receiving no medication ranged from 11.0% in mania to 6.1% in euthymia. Antipsychotics were the most commonly prescribed drug class in all disease phases except for patients with depression, where antidepressants were more frequently prescribed. Visits to the psychiatrist were the most frequently used healthcare resource. These results provide a description of treatment patterns for bipolar disorder across different countries and indicate factors related to relapse and recurrence.

Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial.

BACKGROUND: Little is known about whether treatment in a specialised out-patient mood disorder clinic improves long-term prognosis for patients discharged from initial psychiatric hospital admissions for bipolar disorder. AIMS: To assess the effect of treatment in a specialised out-patient mood disorder clinic v. standard decentralised psychiatric treatment among patients discharged from one of their first three psychiatric hospital admissions for bipolar disorder. METHOD: Patients discharged from their first, second or third hospital admission with a single manic episode or bipolar disorder were randomised to treatment in a specialised out-patient mood disorder clinic or standard care (ClinicalTrials.gov: NCT00253071). The primary outcome measure was readmission to hospital, which was obtained from the Danish Psychiatric Central Register. RESULTS: A total of 158 patients with mania/bipolar disorder were included. The rate of readmission to hospital was significantly decreased for patients treated in the mood disorder clinic compared with standard treatment (unadjusted hazard ratio 0.60, 95% CI 0.37-0.97, P = 0.034). Patients treated in the mood disorder clinic more often used a mood stabiliser or an antipsychotic and satisfaction with treatment was more prevalent than among patients who received standard care. CONCLUSIONS: Treatment in a specialised mood disorder clinic early in the course of bipolar disorder substantially reduces readmission to a psychiatric hospital and increases satisfaction with care.

The societal cost of bipolar disorder in Sweden.

PURPOSE: There is a lack of comprehensive cost-of-illness studies in bipolar disorder, in particular studies based on patient-level data. The purpose of this study was to estimate the societal cost of bipolar disorder and to relate costs to disease severity, depressive episodes, hospitalisation and patient functioning. METHODS: Retrospective resource use data in inpatient and outpatient care during 2006-2008, as well as ICD-10 diagnoses and Global Assessment of Functioning (GAF) scores, were obtained from the Northern Stockholm psychiatric clinic with a catchment area including 47% of the adult inhabitants in Stockholm. This dataset was combined with national register data on prescription pharmaceuticals and sick leave to estimate the societal cost of bipolar disorder. The study was conducted from a societal perspective, with indirect costs valued according to the human capital method. RESULTS: The average annual cost per patient was 28,011 in 2008 (n = 1,846). Indirect costs due to sick leave and early retirement represented 75%, inpatient costs 13%, outpatient costs 8%, pharmaceuticals 2% and community care another 2% of the total cost. Total costs were considerably higher during mood episodes (six times higher than in remission), for hospitalised patients (55,500 vs. 22,200) and for patients with low GAF scores. CONCLUSIONS: The high cost of bipolar disorder is driven primarily by indirect costs. Costs were strongly associated with mood episodes, hospitalisations and low GAF scores. This suggests that treatment that reduces the risk for relapses and hospitalizations and improve functioning may decrease both the societal cost of bipolar disorder and patient suffering.

Benefits of Returning to Work After ECT.

BACKGROUND: Severe unipolar or bipolar depression is often not helped by pharmacotherapy and/or psychotherapeutic treatment alone, whereas more than 80% of these patients remit after sessions of electroconvulsive treatment (ECT). Getting patients back to work after a severe depression may be important for maintaining the effect of ECT. METHODS: Twenty consecutive patients remitted to an acute psychiatric hospital for depression underwent ECT. None of the patients had been working before the inpatient stay. Four patients were living on a permanent sickness allowance from the State (invalidity pension) before ECT, and thus were not expected to start work thereafter. RESULTS: Ten of the patients returned to work. Hospital treatment in Norway (including ECT) is provided free of charge with no copayments from the patient. The mean length of sick leave before ECT was 14.7 months. The 10 patients who returned to work had accrued public costs before their inpatient stays totalling NOK (Norwegian krone) 2,994,635 or a mean of NOK 299,463 per patient (&OV0556;1 = 9 NOK or $1 = 6 NOK ). The total public cost of their inpatient stays was NOK 1,680,000. During the first year after ECT, these 10 patients received NOK 2,680,000 in wages (NOK 3,238,300 during the mean number of months they were observed). CONCLUSION: Most of the patients (10 of 16) receiving ECT returned to work and within 2 years had earned more than the total cost both of their sick leave before admittance to hospital and the public cost of their 4 weeks' inpatient treatment. It is a pity that many countries, including Norway, only allow ECT as a treatment of last resort after failed psychotherapy or pharmacotherapy. Higher public spending is an inadvertent result of such a policy toward ECT.

[Study of the impact of an assertive community program on the families of patients with severe mental disorders]. / Patients souffrant de troubles psychiatriques sévères suivis par une équipe mobile : impact sur leurs familles.

OBJECTIVES: Assertive Community Treatment (ACT) is known to have a positive impact on the number and length of inpatient stays. Yet, research is needed in order to help understand how ACT programs may ease off families' burden, e.g. in terms of economic expenditures. Indeed, many families with siblings suffering from chronic mental illness, who disengaged from psychiatric services, report needs related to ACT. This paper aims to describe the impact of a new ACT program in Geneva on patients and their families' burden. METHODS: Out of 91 patients consecutively treated by the ACT program for at least 3 months, 55 consented to participate in the research. Twenty-one allowed us to contact their families (out of 37 who had relatives in the area). Data were gathered on patients and families before and after a 6-month-follow-up. RESULTS: For the patients, after adjustment for the time spent during follow-up, most of the studied variables evolved favorably, particularly for their symptoms. At baseline, most of the family members felt overburdened by the financial cost (59.1%) related to their relatives with severe mental disorder and experienced inconvenience at having to give them assistance in daily life (68.2%) and to supervise them in daily activities (54.5%). Several variables evolved favorably during follow-up. Notably the best changes were observed for the inconvenience relating to assistance in daily life and relatives' emotional distress. Families of patients with delusional disorder featured less or no improvement during the ACT follow-up. The best correlate of improvement in familial burdens was improvement in patient's positives symptoms. Among those patients, being a female and suffering from a schizo-affective disorder was known to have had a higher impact on the number of interventions provided by families. DISCUSSION: ACT should be recommended for patients who feature a poor outcome when treated in other settings. In addition, our results suggest that their families can also improve considerably, particularly those confronted with patients with persistent and enduring disturbing behaviors related to positive symptoms which do not, however, warrant hospitalization. Clinicians should pay particular attention to patients suffering from delusional disorder and their families, as this disorder does not appear to be associated with improvement in family burdens. These data do not allow definitely disentangling whether the improvement of families' burden is directly related to ACT interventions with them, to the implementation of support by other structures (such as peer support groups) or to an indirect effect related to patients' improvement. To our knowledge no similar study on the effect of ACT on family burden exists. Hence, such research needs to be replicated in other areas with different clinical and cultural backgrounds.