In-patient care costs of patients with bipolar I disorder: a comparison between two European centers.

BACKGROUND: Bipolar disorder (BPD) is a disabling disease with high morbidity rates. An international (Spain, France) comparative study about hospitalizations and in-patient care costs associated with BPD I was performed. Centers were included if they had access to a database of computerized patient charts exhaustively covering a defined catchment area. METHODS: Economic evaluation was performed by multiplying the average cumulated annual length of stay (LOS) of hospitalized bipolar patients by a full cost per day of hospitalization in each center to obtain the corresponding annual costs. RESULTS: Hospitalization rates per annum and per 100,000 individuals (general population aged 15+) were similar between France (43.6) and Spain (43.1). There were only slight differences in relation to length of stay (LOS) per patient hospitalized with 18.1 days in Spain and 20.4 days in France. The overall estimated annual hospitalization costs were in the same order of magnitude after adjustment to an adult population of 100,000: euro 232,000 (Spain) and euro 226,500 (France). Mixed episodes had the longest LOS followed by depressive episodes, while manic episodes had the shortest ones. Mania was the most costly disorder representing 53.7% of annual BPD in-patient care costs. CONCLUSIONS: BPD I care requires large resources and frequent hospitalizations, especially during manic episodes. Depressive and mixed episodes require longer hospital stays than manic episodes. Out-patient costs should now be evaluated.

[The costs of bipolar disorder]. / Coût du trouble bipolaire: revue de la littérature.

INTRODUCTION: According to the estimates of the World Bank and the World Health Organization bipolar disorder is the sixth leading cause of handicap throughout the world. The burden of this disease is similar to the one of schizophrenia. But cost-of-illness studies are too seldom. Although preventive treatments of bipolar disorder are available for more than fifty years, their economic impact has rarely been studied. LITERATURE FINDINGS: This review shows that the yearly cost of bipolar disorder is between 10,000 and 16,000 euro (12,000 and 18,000 US dollars). Eighty percent are indirect costs, 15% are linked to hospitalization and 5% to drugs. Hospitalization costs are lower in Health Maintenance Organization or general population studies than in studies performed on populations receiving care from psychiatric institutions or with a low socio-economic status. DISCUSSION: The use of mood stabilizers has a substantial impact on direct costs which are halved and consequently on indirect costs. But different surveys all agree on the dramatic under-use of mood stabilizers which may be adequately prescribed to only a quarter of bipolar patients. CONCLUSION: Therefore, the optimization of mental health system resources should prompt incentives to better screen, diagnose, and treat patients with a bipolar disorder.

[Bipolar I disorder in France: prevalence of manic episodes and hospitalisation-related costs]. / Le trouble bipolaire I en France: prévalence des épisodes maniaques et coût des hospitalisations pour ce motif.

Bipolar disorder is a chronic, highly disabling illness. However, few studies have evaluated the economic impact of this illness. The objective of this study was to estimate: 1) the annual number of manic episodes in patients with bipolar I disorder, and 2) the costs of hospitalisations related to manic episodes in France. We only included data on bipolar I disorder, as there is greater consensus and better documentation for this subgroup of patients with bipolar disorder. The prevalence of manic episodes was estimated using published epidemiological data. A computerised literature search was performed using the traditional scientific and medical databases. Additional epidemiological references were identified from published studies and textbooks. For hospitalisation data, we used the statistics of the Medical Information Department of a large psychiatric hospital in Paris for the year 1999. We estimated the annual number of manic episodes in France based on: 1) the lifetime prevalence of bipolar I disorder, 2) the average cycle duration, 3) the proportion of rapid cycling patients, and 4) the proportion of depressive vs. manic episodes for patients with bipolar I disorder. In order to estimate the prevalence of bipolar I disorder, we conducted a random effects meta-analysis using published international data. Results of the meta-analysis, which was based on a total of 62 736 patients, showed the lifetime prevalence of bipolar I disorder to be 0.82% [95% CI: 0.42, 1.21]. Applied to the adult population in France, this prevalence implies that the number of persons who have ever experienced a bipolar I -disorder is approximately 390,000 [95% CI: 200,000, 575,000]. Few studies provide information on the duration of cycles in patients with bipolar I disorder. Available estimates suggest the cycle duration to be approximately 12 months. Regarding the proportion of rapid cyclers, data from the meta-analysis by Tondo et al. show that 18% of patients with bipolar disorder experience at least four episodes of mood disorder per year. Finally, based on findings provided by cohort studies, the number of depressive episodes appears to be roughly equal to the number of manic episodes during the course of bipolar disorder. A rapid cycling rate of 18% and a cycle duration of 12 months imply that, on average, among 100 bipolar patients, 18 will have a 3-month cycle duration and 82 a 14-month cycle duration. Given an equal proportion of manic and depressive episodes, the annual number of manic episodes would then be 68 for a cohort of 100 bipolar patients (0.68 episode per patient per year). Applying this figure to the estimate of the total number of patients with bipolar I disorder in France suggests that the annual number of manic episodes in France is 265,000 [95% CI: 136,000, 391,000]. Based on data from a psychiatric hospital in Paris, the proportion of manic episodes that require hospitalisation was estimated to be around 63% with an average length of stay of 32.4 days. Hence the annual number of hospitalisations for manic episodes in France is estimated to be 167 000 [95% CI: 86 000, 246 000] and the hospitalisation-related costs 1,3 billion euros approximately. Our review of literature highlights the lack of medical and economic data at the national level on the frequency and hospitalisation-related costs of manic episodes in patients with bipolar I disorder in France. Given the lifetime prevalence of bipolar I disorder which may be as high as 3% among adults, further studies are required in order to provide representative national data and to allow economic evaluations of costs related to bipolar disorder in France.

Economic assessment of a maintenance treatment strategy in prevention of recurrent depressive disorder.

OBJECTIVE: To compare the 12-month cost-effectiveness of milnacipran in maintenance treatment of depression to that of medical follow-up without antidepressant. METHOD: A Markov model with transition probabilities from a double blind clinical trial demonstrating the prophylactic efficacy of milnacipran was used. Other parameters were obtained from published sources. RESULTS: Base-case incremental cost for preventive treatment was 1,191 FF. It was reduced to 685 FF when using a 25% hospitalization rate in case of recurrence. Patients with a high initial response had extra cost of 191 FF and cost-utility was estimated to be 23,875 FF per QALY gained. For those patients, using a 25% hospitalization rate in case of recurrence, costs were lower at 1,174 FF and preventive strategy was dominating. CONCLUSION: Cost of maintenance therapy is partially balanced by the gain from recurrence prevention. It should be focused on patients with few residual symptoms or a high probability of hospitalization in case of recurrence.

[Clinico-economic assessment of milnacipran in the prevention of depressive episodes]. / Evaluation médico-économique de milnacipran dans la prévention des épisodes dépressifs.

The objective of this study was to evaluate, for patients at risk of a new depressive episode, the net cost of maintenance therapy with milnacipran compared with a symptomatic treatment of further episodes. Using clinical decision analysis techniques, a Markov-state transition was constructed to estimate the 12 months direct costs of the two therapeutic strategies. Model construction and probabilities for performing the analysis were primarily based on a controlled phase III clinical trial demonstrating the prophylactic efficacy of milnacipran compared to placebo. Others parameters and unit costs were obtained from published sources. For each group (maintenance and episodic treatment groups), the model simulated the clinical evolution of patients on 6 successive 2-months cycles. Costs were affected for each health state period (remission, depression, abandonment of health care, suicide). The baseline analysis showed the mean costs per patient and year were 627 FF (105 US$) higher for maintenance treatment. Sensitivity analysis suggested that costs were equal under a 25% rate of hospitalization hypothesis for a depressive episode. Maintenance costs were 1,587 FF (265 US$) lower than episodic treatment costs for depressed subjects with a good initial response to milnacipran (HDRS-21 score at remission < 5); this economic benefit remained under a lower rate of hospitalization hypothesis (12%). Based on the study assumptions, maintenance treatment with milnacipran appears to be clinically and economically justified for patients at high risk of hospitalization when having a recurrence, and even more for patients with an excellent initial acute response.

[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.

Comparison of the cost-effectiveness of milnacipran (a SNRI) with TCAs and SSRIs: a modeling approach.

A simulation model based on the theory of clinical decision analysis was used to compare outcomes and costs when treating patients with major depressive episodes using either a selective serotonin re-uptake inhibitor (SSRI) or a tricyclic antidepressant (TCA), in comparison with milnacipran (a serotonin), and a norepinephrine re-uptake inhibitor (SNRI). The clinical data used were taken from published meta-analyses. This analysis supports: (1) a comparable efficacy of milnacipran and TCA with a better tolerance; and, (2) an advantage of milnacipran over SSRI for efficacy with a comparable tolerance. Based on these findings, a decision tree was constructed with the assistance of a panel of psychiatrists in order to provide a model of usual clinical practice. Estimates not available from clinical studies were obtained either from literature analysis or from the panel. Economic appraisal was performed according to the viewpoint of the French national sickness fund (sécurité sociale), and expenditure assessment was limited to direct costs (hospitalizations, antidepressant medications, visits, and laboratory tests). The results suggest that milnacipran is a cost-effective alternative: the expected cost of treatment per depressive episode is lower than either a French representative panel of TCAs (a saving of 288 FF), or SSRIs (a savings of 961 FF). The expected length of clinical remission is slightly higher than comparators. The robustness of these findings was supported by sensitivity analyses.