The economic impact of bipolar disorder in an employed population from an employer perspective

Right frontal cingulate cortex mediates the effect of prenatal complications on youth internalizing behaviors

Prenatal and perinatal complications represent well-known risk factors for the future development of psychiatric disorders. Such influence might become manifested during childhood and adolescence, as key periods for brain and behavioral changes. Internalizing and externalizing behaviors in adolescence have been associated with the risk of psychiatric onset later in life. Both brain morphology and behavior seem to be affected by obstetric complications, but a clear link among these three aspects is missing. Here, we aimed at analyzing the association between prenatal and perinatal complications, behavioral issues, and brain volumes in a group of children and adolescents. Eighty-two children and adolescents with emotional-behavioral problems underwent clinical and 3 T brain magnetic resonance imaging (MRI) assessments. The former included information on behavior, through the Child Behavior Checklist/6-18 (CBCL/6-18), and on the occurrence of obstetric complications. The relationships between clinical and gray matter volume (GMV) measures were investigated through multiple generalized linear models and mediation models. We found a mutual link between prenatal complications, GMV alterations in the frontal gyrus, and withdrawn problems. Specifically, complications during pregnancy were associated with higher CBCL/6-18 withdrawn scores and GMV reductions in the right superior frontal gyrus and anterior cingulate cortex. Finally, a mediation effect of these GMV measures on the association between prenatal complications and the withdrawn dimension was identified. Our findings suggest a key role of obstetric complications in affecting brain structure and behavior. For the first time, a mediator role of frontal GMV in the relationship between prenatal complications and internalizing symptoms was suggested. Once replicated on independent cohorts, this evidence will have relevant implications for planning preventive interventions.

Is There Somebody Looking out for Me? A Qualitative Analysis of Bullying Experiences of Individuals Diagnosed with Bipolar Disorder

According to the World Health Organisation, there are globally 40 million individuals with bipolar disorder (BD), and they experience stigma and discrimination, as many people with mental illness do. Work bullying (WB) is a common organisational problem, deteriorating the well-being and performance of employees and organisations. Although WB experiences have been researched for over three decades, we do not know much about the experiences of this group and what they need to extend their work-life. The current research aims to understand the workplace bullying experiences of individuals with BD and factors that may foster or hinder their participation in the labour force. The research methodology was based on in-depth interviews with 19 employees diagnosed with BD. Bullying experiences were mapped onto the Negative Acts Questionnaire. The data were analysed using the deductive qualitative content analysis on MAXQDA. Results showed that individuals with BD were exposed to bullying in work settings. Perceived reasons for the negative behaviours were mainly the undesirable individual characteristics of the bully, prejudices toward bipolar disorder, and already-existing toxic behaviours within the organisation. To reduce bullying, participants suggested that, among others, top management include equal and fair treatment of disadvantaged employees as performance criteria for supervisors and that organisations provide training against bullying, investigate complaints, apply sanctions, and establish an inclusive environment. If organisations set a stable and enduring vision, enhance a common identity for all employees, work on team building, and emphasise team efforts and goals, the organisational environment would be more inclusive, and individuals with BD would have longer work lives.

Economic Burden Associated With Untreated Mental Illness in Indiana

Importance

There is a paucity of systematically captured data on the costs incurred by society-individuals, families, and communities-from untreated mental illnesses in the US. However, these data are necessary for decision-making on actions and allocation of societal resources and should be considered by policymakers, clinicians, and employers.

Objective

To estimate the economic burden associated with untreated mental illness at the societal level.

Design, Setting, and Participants

This cross-sectional study used multiple data sources to tabulate the annual cost of untreated mental illness among residents (≥5 years old) in Indiana in 2019: the US National Survey on Drug Use and Health, the National Survey of Children's Health, Indiana government sources, and Indiana Medicaid enrollment and claims data. Data analyses were conducted from January to May 2022.

Main Outcomes and Measures

Direct nonhealth care costs (eg, criminal justice system, homeless shelters), indirect costs (unemployment, workplace productivity losses due to absenteeism and presenteeism, all-cause mortality, suicide, caregiver direct health care, caregiver productivity losses, and missed primary education), and direct health care costs (disease-related health care expenditures).

Results

The study population consisted of 6 179 105 individuals (median [SD] age, 38.0 [0.2] years; 3 132 806 [50.7%] were women) of whom an estimated 429 407 (95% CI, 349 526-528 171) had untreated mental illness in 2019. The economic burden of untreated mental illness in Indiana was estimated to be $4.2 billion annually (range of uncertainty [RoU], $2.1 billion-$7.0 billion). The cost of untreated mental illness included $3.3 billion (RoU, $1.7 billion-$5.4 billion) in indirect costs, $708.5 million (RoU, $335 million-$1.2 billion) in direct health care costs, and $185.4 million (RoU, $29.9 million-$471.5 million) in nonhealth care costs.

Conclusion and Relevance

This cross-sectional study found that untreated mental illness may have significant financial consequences for society. These findings put into perspective the case for action and should be considered by policymakers, clinicians, and employers when allocating societal resources and funding. States can replicate this comprehensive framework as they prioritize key areas for action regarding mental health services and treatments.

Effects of Exercise on Functional Recovery in Patients with Bipolar Depression: A Study Protocol for a Randomized Controlled Trial

Treatment of bipolar disorder is prone to prolongation despite various treatments, including medication. The efficacy of exercise treatment (i.e., interventions involving physical exercise and sports intervention) for major depressive disorders has been reported for depressive symptoms, cognitive function, and sleep disturbances. However, its efficacy for bipolar disorder has yet to be established. We designed a randomized, controlled, double-blind clinical trial that includes 100 patients with bipolar disorder aged 20-65 years. This will be a cluster-randomized, two-group trial that will be conducted in ten psychiatric hospitals. The hospitals will be randomly assigned to an exercise intervention + treatment as usual (exercise) group or a placebo exercise intervention (stretching) + treatment as usual (control) group. Patients will be assessed using an extensive battery of clinical tests, physical parameters, sleep status, biological parameters (cytokines, neurotrophic factors), and genetic parameters (DNA and RNA) at baseline after a 6-week intervention period, at 10-week follow-up, and at 6-month follow-up. This innovative study may provide important evidence for the effectiveness of exercise in the treatment of bipolar depression based on clinical, biological, genetic, and physiological markers.

Evaluation of patient social support, caregiver burden, and their relationship with the course of the disease in patients with bipolar disorder

BACKGROUND

Bipolar disorder is a chronic disorder that causes significant effects on the patient and exerts a significant care burden on caregivers. This study aimed to investigate the social support of patients, caregivers' burden and their impact on the clinical course of the disease.

METHODS

The study included 85 patients with bipolar disorder type I and II (in the recovery phase of the disease) and their caregivers in the age range of 18 to 60 years. It was conducted in Shafa psychiatry Hospital in Rasht (Guilan, Iran, 2020). To assess social support and burden, patients and caregivers completed the Multidimensional Perceived Social Support Scale (MSPSS) and Caregiver Burden Inventory (CBI), respectively. Clinical variables were also obtained from patients' medical records; Then ANOVA, MANOVA, Independent T-test were used to compare the data and Regression Analysis and Spearman correlation coefficient were used to find the relationships between variables.

RESULTS

It was showed that increasing patient social support is associated with reducing caregiver burden. Among the clinical variables, less social support and more caregiver burden were associated with longer duration of illness (p < .0029, p < .012), decrease in last recurrence time (p < .0013, p < .0001), increased number of hospitalizations (p < .0001, r = -.43 and p < .0001, r = +.49), decreased response to treatment (p < .0001, p < .0001), and reduced follow-up (p = .001, OR = 1.12 and p = .001, OR = 0.95).

CONCLUSION

The relationship between low social support and high caregiver burden and their significant effect on the disease course indicates a vicious cycle that affects patients, caregivers, and the clinical course of the disease. Therefore, it seems that interventions to break this cycle can change the situation in favor of patients and caregivers and improve the clinical course of the disease.

Incidence of and risk factors for alcohol dependence in bipolar disorder: A population-based cohort and nested case-control study

OBJECTIVES

Although alcohol dependence is highly prevalent in patients with bipolar disorder, the causal relationship is not yet well-established. This study estimated the incidence of alcohol dependence in a nationwide bipolar disorder cohort and examined risk factors for alcohol dependence.

METHODS

Patients aged 15-65 years with consistent bipolar disorder who had their first psychiatric admission between 1999 and 2012 (n = 21,791) were enrolled from the National Health Insurance Research Database in Taiwan. We calculated the adjusted incidence rate ratio of alcohol dependence in the bipolar cohort relative to the general population after stratification by age and sex. In the nested case-control study, we included patients with incident alcohol dependence as cases and four age- and sex-matched controls for each case to analyze health care utilization, comorbidities and concomitant medications between them.

RESULTS

We identified 1261 patients with bipolar disorder with incident alcohol dependence. Relative to the general population, the adjusted incidence rate ratio of alcohol dependence was 9.20 in the bipolar cohort. All adjusted incidence rate ratios were high across all age subgroups. Cases had higher psychiatric and nonpsychiatric health care utilization than did controls. Multivariate analysis revealed that cases tended to have cardiovascular disease, diabetes mellitus, chronic hepatic disease, pneumonia and delirium before alcohol dependence diagnosis. Cases had higher psychiatric comorbidities, namely drug-induced mental disorders, anxiety disorder, personality disorder, adjustment disorder and sleep disorder.

CONCLUSION

The bipolar cohort had a higher incidence of alcohol dependence. We identified specific groups with a high risk of alcohol dependence. Additional strategies for early detection, treatment and intervention for alcohol dependence should be developed.

Long-Term Healthcare Utilization and the Cost of Bipolar Disorder Among Participants in a Large Employer's Health Benefit Plan

OBJECTIVE

Bipolar disorder (BD) is a chronic illness with recurrent exacerbations. The objective was to evaluate longitudinal costs related to BD in an employer-sponsored medical plan.

METHODS

This analysis utilized 5 years of administrative claims data. Claimants with a diagnosis of BD were matched to plan members (1:5) based on age, sex, and years of follow-up.

RESULTS

Medical costs for hospitalized BD members were 3.5 times more expensive than the general population (BDhosp = $92.2K vs General population = $26.8K). Average 5-year paid costs among hospitalized members with BD was $107K, $105.4K with cancer, and $103.3K with myocardial infarction (MI).

CONCLUSIONS

Hospitalized BD plan members consumed more than 3.5 times the medical resources and were similar in longitudinal costs when compared with members with other costly conditions. These findings highlight the need for novel employer-sponsored programs to help manage BD.

The impact of bipolar spectrum disorders on professional functioning: A systematic review

AIMS

The impact of bipolar spectrum (BS) disorders on professional functioning has not been systematically reviewed yet. Since even subsyndromal symptoms may disturb functioning, the determination of the prognostic value of the spectrum of bipolarity for employment seems extremely relevant. The aim of this study was to assess the impact of BS disorders on professional functioning.

MATERIALS AND METHODS

A systematic review of the literature (namely, cohort and cross-sectional studies) investigating a link between BS disorders and employment was performed in accordance with PRISMA guidelines. BS was defined based on the concept of two-dimensional BS by Angst. Occupational outcomes and factors affecting employment were evaluated as well.

RESULTS

Seventy-four studies were included. All disorders comprising BS had a negative impact on occupational status, work performance, work costs, and salary, with the greatest unfavorable effect reported by bipolar disorder (BD), followed by borderline personality disorder (BPD), major depressive disorder (MDD), and dysthymia. Employment rates ranged from 40 to 75% (BD), 33 to 67% (BPD), 61 to 88% (MDD), and 86% (dysthymia). The factors affecting employment most included: cognitive impairments, number/severity of symptoms, namely, subsyndromal symptoms (mainly depressive), older age, education, and comorbidity (substance abuse, personality disorders, anxiety, depression, ADHD, PTSD).

CONCLUSION

Bipolar spectrum symptoms exert a negative impact on professional functioning. Further evaluation of affecting factors is crucial for preventing occupational disability.

Treatment-Resistant Bipolar Depression: Therapeutic Trends, Challenges and Future Directions

INTRODUCTION

Bipolar disorder (BD) is a chronic mental illness impacting 1-2% of the population worldwide and causing high rates of functional impairment. Patients with BD spend most of their time in depressive episodes and up to one-third of patients do not respond to adequate doses of medications. Although no consensus exists for definition of treatment-resistant bipolar depression (TRBD), failure of symptoms improvement despite an adequate trial of two therapeutic agents is a common theme of TRBD. In this paper, we review the evidence base of therapeutic interventions, challenges, and potential future directions for TRBD.

METHODS

We conducted a literature search for randomized controlled trials on PubMed for the treatment of TRBD and ongoing trials for the treatment of TRBD/bipolar depression on clinicaltrials.gov.

RESULTS

Several therapeutic agents have been investigated for TRBD. Adjunctive pramipexole and modafinil have data supporting short-term efficacy in TRBD, along with limited data for racemic intravenous ketamine. Celecoxib augmentation of escitalopram and treatment with metformin in patients with insulin resistance showed promising results. Right unilateral electroconvulsive therapy displayed statistically significant response rate and improvement, but not remission compared to pharmacotherapy. Trials for transcranial magnetic stimulation (TMS) have failed to show a significant difference from sham treatment in TRBD.

FUTURE TRENDS

Pharmacological treatments with novel mechanisms of actions like brexpiprazole and vortioxetine are being investigated following successes in unipolar depression. Modified TMS protocols such as accelerated TMS are under investigation. Innovative approaches like psychedelic-assisted psychotherapy, interleukin-2, fecal microbiota transplantation and multipotent stromal cells are being studied.

CONCLUSION

Evidence on current treatment modalities for TRBD is limited with low efficacy. More research is needed for successful treatment of TRBD. Effective therapies and innovative approaches to treatment are being investigated and could show promise.

Disability and workers' compensation trends for employees with mental disorders and SUDs in the United States

Introduction

US employee absence benefits may include workers' compensation (WC) for work-related injuries/illnesses, short- and long-term disability (STD and LTD, respectively) for non–work-related injuries/illnesses, and discretionary sick leave (SL). Absences can significantly impact business performance, and employers are intensifying efforts to manage benefits and connections with employee health. This research compares all-cause STD/LTD/WC/SL use and variation from baseline (2002) for eligible employees (EMPs) with mental disorders (MDs) and SUDs to determine if use/payments varied over time.

Methods

Employees incurring medical claims with Agency for Healthcare Research and Quality MD and SUD ICD-9/10 codes were identified in the WorkPartners database (January 1, 2002 to December 31, 2019). Retrospective analysis was performed on annual prevalence, benefit use, mean days of leave, and median payments as a percent of salary (including lump-sum distributions and potentially extending beyond initiation year). WC claims without work absences were excluded. For each benefit, annual outcomes were calculated as a percent of baseline to show variability.

Results

Use was 48.1% to 202.2% (median, 102.8%) of baseline rates for SL (SUD-EMPs), and 87.3% to 108.4% (median, 97.3%) for STD (MD-EMPs). Days of LTD leaves were 21.5% to 657.8% (median, 359.2%) of baseline days (MD-EMPs), and 122.7% to 1042.2% (median, 460.0%) of baseline days for (SUD-EMPs). Median payments for WC were 78.6% to 253.6% (median, 114.6%) of baseline (MD-EMPs) and 97.9% to 481.6% (median, 104.0%) for SUD-EMPs.

Discussion

Employees with MD/SUD used absence benefits at differing rates over time with varying days of leave and payments as a percent of salary. Using a constant cost or salary replacement factor over time for all benefits is not accurate or appropriate.

Lurasidone in the long-term treatment of Japanese patients with bipolar I disorder: a 52 week open label study

Background

The current study evaluated the long-term (52 week) safety and impact on symptom measures of lurasidone (with or without lithium or valproate) for the treatment of bipolar I disorder in Japanese patients.

Methods

Bipolar patients for this open-label flexibly dosed lurasidone (20–120 mg/day) study were recruited from those with a recent/current depressive episode who completed an initial 6 week, double-blind, placebo-controlled, lurasidone study (depressed group), and those with a recent/current manic, hypomanic, or mixed episode (non-depressed group) who agreed to enroll directly into the long-term study. Measures of adverse events and safety included treatment-emergent adverse events, vital signs, body weight, ECG, laboratory tests, and measures of suicidality and extrapyramidal symptoms. Symptom measures included Montgomery Åsberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS).

Results

The most common adverse events associated with lurasidone were akathisia (30.7%), nasopharyngitis (26.6%), nausea (12.1%), and somnolence (12.1%). Minimal changes in lipids and measures of glycemic control occurred. Mean change in body weight was + 1.0 kg in the non-depressed group and − 0.8 kg in the depressed group. MADRS total scores declined by a mean (SD) of 2.0 (14.7) points from long-term baseline to endpoint in the depressed group who had received placebo in the prior 6 week trial. The depressed group that had received lurasidone during the prior 6 week study maintained their depressive symptom improvements. For the non-depressed group, YMRS total scores decreased over time.

Limitations

No control group was included, treatment was open-label, and 49.7% of patients completed the 52 week study.

Conclusions

Long-term treatment with lurasidone 20–120 mg/day for Japanese patients with bipolar disorder maintained improvements in depressive symptoms for depressed patients who were treated in a prior 6 week trial and led to improvements in manic symptoms among a newly recruited subgroup of patients with a recent/current manic, hypomanic, or mixed episode. Few changes in weight or metabolic parameters were evident.

Clinical trial registration: JapicCTI-132319, clinicaltrials.gov—NCT01986114.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-021-00230-8.

Mental health: The burden of social stigma

The burden of mental health has two facets, social and psychological. Social stigma causes individuals who suspect to be suffering from a mental condition to conceal it, importantly by seeking care from a nonspecialist provider willing to diagnose it as physical disease. In this way, social stigma adds to both the direct and indirect cost of mental health. A microeconomic model depicting an individual who searches for an accommodating provider leads to the prediction that individuals undertake more search in response to a higher degree of social stigma. However, this holds only in the absence of errors in decision-making, typically as long as mental impairment is not too serious. While government and employers have an incentive to reduce the burden of social stigma, their efforts therefore need to focus on persons with a degree of mental impairment that still allows them to avoid errors in pursuing their own interest.

Lurasidone in the Long-Term Treatment of Bipolar I Depression: A 28-week Open Label Extension Study

BACKGROUND

Lurasidone has demonstrated efficacy for short-term treatment of bipolar depression in a diverse ethnic population including Japanese. This study evaluated the long-term safety and effectiveness of open-label lurasidone treatment in these patients.

METHODS

Patients for this 28-week extension study were recruited from those who completed a 6-week double-blind study of lurasidone, 20-60 mg/day, lurasidone 80-120 mg/day, and placebo. In the extension study, lurasidone was flexibly dosed (20 to 120 mg/day). Safety was evaluated in terms of change from extension-phase baseline to endpoint including adverse events, vital signs, body weight, ECG, laboratory tests, and measures of suicidality and extrapyramidal symptoms. Effectiveness was determined by Montgomery Åsberg Depression Rating Scale (MADRS) and other measures.

RESULTS

303 of 413 (73.3%) subjects completed the extension study. Discontinuation due to a treatment-emergent adverse event occurred for 11.4% of those who received placebo, and 8.9% of those who received lurasidone, in the prior 6-week trial. The most common treatment-emergent adverse event was akathisia. Minimal changes were evident on body weight and metabolic parameters. Long-term treatment with lurasidone further reduced mean MADRS total scores from long-term baseline to week 28 (or endpoint) for both those who had received prior placebo (-11.3), and those who had receive prior lurasidone (-8.9), in the 6-week double-blind trial.

LIMITATIONS

There was no placebo control and treatment was not double-blind.

CONCLUSIONS

Long-term treatment with lurasidone (20-120 mg/day) was well-tolerated with no new safety concerns and associated with continued improvement in depressive symptoms in this international sample of patients with bipolar depression.

CLINICAL TRIAL REGISTRATION

JapicCTI-132319, clinicaltrials.gov - NCT01986114.

Double-blind, placebo-controlled study of lurasidone monotherapy for the treatment of bipolar I depression

AIM

Previous studies conducted primarily in the USA and Europe have demonstrated the efficacy and safety of lurasidone 20-120 mg/day for the treatment of bipolar I depression. The aim of the current study was to evaluate the efficacy and safety of lurasidone monotherapy for the treatment of bipolar I depression among patients from diverse ethnic backgrounds, including those from Japan.

METHODS

Patients were randomly assigned to double-blind treatment for 6 weeks with lurasidone, 20-60 mg/day (n = 184) or 80-120 mg/day (n = 169), or placebo (n = 172). The primary end-point was change from baseline to Week 6 on the Montgomery-Åsberg Depression Rating Scale (MADRS).

RESULTS

Lurasidone treatment significantly reduced mean MADRS total scores from baseline to Week 6 for the 20-60-mg/day group (-13.6; adjusted P = 0.007; effect size = 0.33), but not for the 80-120-mg/day group (-12.6; adjusted P = 0.057; effect size = 0.22) compared with placebo (-10.6). Treatment with lurasidone 20-60 mg/day also improved MADRS response rates, functional impairment, and anxiety symptoms. The most common adverse events associated with lurasidone were akathisia and nausea. Lurasidone treatments were associated with minimal changes in weight, lipids, and measures of glycemic control.

CONCLUSION

Monotherapy with once daily doses of lurasidone 20-60 mg, but not 80-120 mg, significantly reduced depressive symptoms and improved functioning in patients with bipolar I depression. Results overall were consistent with previous studies, suggesting that lurasidone 20-60 mg/day is effective and safe in diverse ethnic populations, including Japanese.

Circulating Brain-Derived Neurotrophic Factor, Antioxidant Enzymes Activities, and Mitochondrial DNA in Bipolar Disorder: An Exploratory Report

AIM

Accumulated evidence indicates that neurotrophin deregulations, oxidative stress injury, and mitochondrial dysfunction have been involved in bipolar disorder (BD); however, their real roles in BD are unclear. Investing the possible interaction between three systems is worthwhile understanding this complex process.

METHODS

We measured plasma brain-derived neurotrophic factor (BDNF) level, leukocytes mitochondrial DNA copy number (mtDNAcn), and activities of antioxidant enzymes in BD patients (n = 97) and healthy controls (n = 31). Analysis of variance and linear regression analyses were performed to explore the interaction between mtDNAcn, antioxidant enzymes, and BDNF.

RESULTS

Compared with healthy controls, there were significant decreases of glutathione peroxidase activity, BDNF levels, and mtDNA content, significant increases of manganese superoxide dismutase (MnSOD) activity among BD patients (all p < 0.05). Regression analysis showed MnSOD activity had a moderate effect on BDNF (beta = 0.23, t = 8.5, p = 0.001). Copper zinc SOD and total SOD activity were significantly correlated with Hamilton Depression Scale scores in depressive patients (r = -0.38, p = 0.013; r = -0.35, p = 0.022). Unexpectedly, we observed no significant correlation between mtDNA content and BDNF in BD patients (p > 0.05).

CONCLUSION

The findings coincide with our hypothesis that abnormal antioxidant enzymes, mtDNAcn, and peripheral BDNF may be involved in the course of BD. There were significant correlations between peripheral BDNF, antioxidant enzyme activities and mtDNAcn, suggesting that oxidative stress, mitochondrial function, and BDNF may influence each other in BD.

Changes in cortical thickness and volume of cerebellar subregions in patients with bipolar disorders

BACKGROUND

Numerous studies have suggested that structural changes in the cerebellum are implicated in the pathophysiology of bipolar disorder (BD). We aimed to investigate differences in the volume and cortical thickness of the cerebellar subregions between patients with BD and healthy controls (HCs).

METHODS

Ninety patients with BD and one hundred sixty-six HCs participated in this study and underwent T1-weighted structural magnetic resonance imaging. We analyzed the volume and cortical thickness of each cerebellar hemisphere divided into 12 subregions using T1-weighted images of participants. One-way analysis of covariance was used to evaluate differences between the groups, with age, sex, medication, and total intracranial cavity volume used as covariates.

RESULTS

The BD group had significantly increased cortical thickness of the cerebellum in all cerebellar subregions compared to the HC group. The cortical thicknesses of the whole cerebellum and each hemisphere were also significantly thicker in the BD group than in the HC group. The volume of the left lobule IX was significantly lower in patients with BD than in HCs, whereas no significant differences in the volumes were observed in the other subregions.

LIMITATIONS

Our cross-sectional design cannot provide a causal relationship between the increased cortical thickness of the cerebellum and the risk of BD.

CONCLUSIONS

We observed widespread and significant cortical thickening in all the cerebellar subregions. Our results provide evidence for the involvement of the cerebellum in BD. Further studies are required to integrate neurobiological evidence and structural brain imaging to elucidate the pathophysiology of BD.

Expert consensus on information sheet proposals for patients under treatment with lithium

INTRODUCTION

Lithium is one of the first therapeutic options for bipolar disorder, which is characterized by recurrent mood swings that strongly reduce quality of life. Our purpose was to achieve professional consensus criteria to define the contents of an information sheet for patients with bipolar disorder that are starting treatment with lithium.

MATERIAL AND METHODS

A modified Delphi method in two rounds was used. The Scientific Committee-made up by nine psychiatrists-created a 20-item questionnaire about the information that must be given to the patient treated with lithium and selected a panel of ambulatory and hospital psychiatric experts to agree on this information. Panelists scored each item based on a Likert scale of 9 points and could add comments in a confidential manner. It was considered consensus in agreement when median scores were within the range of [7-9] and in disagreement within the range of [1-3].

RESULTS

A high level of consensus was reached. In the first round, there was agreement on 17 out of 20 items and, after the second round, there was disagreement on just one item containing information about the discovery of lithium. Finally, said item was modified in the Patient's Information Sheet based on the comments suggested by the panelists.

CONCLUSIONS

This study allowed to create an information sheet for patients with bipolar disorder under treatment with lithium, with information agreed upon by a group of experts from different health care settings.

"Why have I not been told about this?": a survey of experiences of and attitudes to advance decision-making amongst people with bipolar

Background: The idea that people with severe mental illness should be able to plan in advance for periods of illness as a means of enhancing autonomy has been long debated and is increasingly being enshrined in codes of practice and mental health legislation. It has been argued that the ethical imperative for this is especially pronounced in bipolar (BP), a condition in which sufferers often experience episodic crises interspersed with periods of wellness. However, there is a paucity of published research investigating experiences of advance decision making (ADM) in people with BP or their attitudes towards it.

Methods: An online survey of BPUK’s mailing list was conducted. 932 people with BP completed the survey (response rate 5.61%). Descriptive statistics and regression analysis were conducted to compare experience of with attitudes towards ADM and variables associated with interest in ADM.

Results: A majority indicated a desire to plan care in advance of losing capacity (88%) but most had not done so (64%). High numbers of respondents expressed a wish to request as well as refuse treatment and most wanted to collaborate with psychiatrists, including on issues around self-binding. The most frequent motivation to utilise ADM was a desire to be more involved in mental health decisions. Interest in self-binding was associated with experience of compulsory treatment and trust in mental health services. Interest in refusals of all medication was associated with younger age and lack of trust in mental health services. Interest in ADM in general was associated with younger age but not educational level, ethnicity or gender.

Conclusions: This study demonstrates an appetite for ADM amongst people with bipolar that is independent of educational status and ethnicity. As states reform their mental health laws, attention needs to be given to the distinctive attitudes toward ADM amongst people with bipolar.

“Why have I not been told about this?”: a survey of experiences of and attitudes to advance decision-making amongst people with bipolar

Background: The idea that people with severe mental illness should be able to plan in advance for periods of illness as a means of enhancing autonomy has been long debated and is increasingly being enshrined in codes of practice and mental health legislation. It has been argued that the ethical imperative for this is especially pronounced in bipolar (BP), a condition in which sufferers often experience episodic crises interspersed with periods of wellness. However, there is a paucity of published research investigating experiences of advance decision making (ADM) in people with BP or their attitudes towards it. Methods: An online survey of BPUK’s mailing list was conducted. 932 people with BP completed the survey (response rate 5.61%). Descriptive statistics and regression analysis were conducted to compare experience of with attitudes towards ADM and variables associated with interest in ADM. Results: A majority indicated a desire to plan care in advance of losing capacity (88%) but most had not done so (64%). High numbers of respondents expressed a wish to request as well as refuse treatment and most wanted to collaborate with psychiatrists, including on issues around self-binding. The most frequent motivation to utilise ADM was a desire to be more involved in mental health decisions. Interest in self-binding was associated with experience of compulsory treatment and trust in mental health services. Interest in refusals of all medication was associated with younger age and lack of trust in mental health services. Interest in ADM in general was associated with younger age but not educational level, ethnicity or gender. Conclusions: This study demonstrates an appetite for ADM amongst people with bipolar that is independent of educational status and ethnicity. As states reform their mental health laws, attention needs to be given to the distinctive attitudes toward ADM amongst people with bipolar.

Associations of Comorbid Anxiety With Medication Adherence and Psychiatric Symptomatology in a Population of Nonadherent Bipolar Disorder Subjects

This analysis was conducted on baseline data from 178 nonadherent bipolar disorder subjects in a randomized controlled trial. Medication adherence was measured with Tablets Routine Questionnaire as percentage of days with missed doses. Inclusion criteria required at least 20% nonadherence. Medication adherence, symptomatology, and functioning in individuals with and without a comorbid anxiety disorder were compared. There were 78.9% of subjects who had at least one or more current anxiety disorder, with the most common being posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. The percentage of days with missed doses over the past month was significantly lower in those with anxiety disorders compared with those without (40.1% vs 50.5%, p = 0.03). Those with comorbid anxiety disorders and those with greater number of anxiety disorder diagnoses had significantly worse mean scores on the Montgomery-Åsberg Depression Rating Scale, Brief Psychiatric Rating Scale, Clinical Global Impression-Bipolar Version, and Global Assessment of Functioning.

Bipolar disorders

Bipolar disorders are chronic and recurrent disorders that affect >1% of the global population. Bipolar disorders are leading causes of disability in young people as they can lead to cognitive and functional impairment and increased mortality, particularly from suicide and cardiovascular disease. Psychiatric and nonpsychiatric medical comorbidities are common in patients and might also contribute to increased mortality. Bipolar disorders are some of the most heritable psychiatric disorders, although a model with gene-environment interactions is believed to best explain the aetiology. Early and accurate diagnosis is difficult in clinical practice as the onset of bipolar disorder is commonly characterized by nonspecific symptoms, mood lability or a depressive episode, which can be similar in presentation to unipolar depression. Moreover, patients and their families do not always understand the significance of their symptoms, especially with hypomanic or manic symptoms. As specific biomarkers for bipolar disorders are not yet available, careful clinical assessment remains the cornerstone of diagnosis. The detection of hypomanic symptoms and longtudinal clinical assessment are crucial to differentiate a bipolar disorder from other conditions. Optimal early treatment of patients with evidence-based medication (typically mood stabilizers and antipsychotics) and psychosocial strategies is necessary.

Hippocampal subfield volumes in mood disorders

Volume reduction and shape abnormality of the hippocampus have been associated with mood disorders. However, the hippocampus is not a uniform structure and consists of several subfields, such as the cornu ammonis (CA) subfields CA1-4, the dentate gyrus (DG) including a granule cell layer (GCL) and a molecular layer (ML) that continuously crosses adjacent subiculum (Sub) and CA fields. It is known that cellular and molecular mechanisms associated with mood disorders may be localized to specific hippocampal subfields. Thus, it is necessary to investigate the link between the in vivo hippocampal subfield volumes and specific mood disorders, such as bipolar disorder (BD) and major depressive disorder (MDD). In the present study, we used a state-of-the-art hippocampal segmentation approach, and we found that patients with BD had reduced volumes of hippocampal subfields, specifically in the left CA4, GCL, ML and both sides of the hippocampal tail, compared with healthy subjects and patients with MDD. The volume reduction was especially severe in patients with bipolar I disorder (BD-I). We also demonstrated that hippocampal subfield volume reduction was associated with the progression of the illness. For patients with BD-I, the volumes of the right CA1, ML and Sub decreased as the illness duration increased, and the volumes of both sides of the CA2/3, CA4 and hippocampal tail had negative correlations with the number of manic episodes. These results indicated that among the mood disorders the hippocampal subfields were more affected in BD-I compared with BD-II and MDD, and manic episodes had focused progressive effect on the CA2/3 and CA4 and hippocampal tail.

Decreased empathy response to other people's pain in bipolar disorder: evidence from an event-related potential study

Bipolar disorder (BD) patients often demonstrate poor socialization that may stem from a lower capacity for empathy. We examined the associated neurophysiological abnormalities by comparing event-related potentials (ERP) between 30 BD patients in different states and 23 healthy controls (HCs, matched for age, sex, and education) during a pain empathy task. Subjects were presented pictures depicting pain or neutral images and asked to judge whether the person shown felt pain (pain task) and to identify the affected side (laterality task) during ERP recording. Amplitude of pain-empathy related P3 (450-550 ms) of patients versus HCs was reduced in painful but not neutral conditions in occipital areas [(mean (95% confidence interval), BD vs. HCs: 4.260 (2.927, 5.594) vs. 6.396 (4.868, 7.924)] only in pain task. Similarly, P3 (550-650 ms) was reduced in central areas [4.305 (3.029, 5.581) vs. 6.611 (5.149, 8.073)]. Current source density in anterior cingulate cortex differed between pain-depicting and neutral conditions in HCs but not patients. Manic severity was negatively correlated with P3 difference waves (pain - neutral) in frontal and central areas (Pearson r = -0.497, P = 0.005; r = -0.377, P = 0.040). Electrophysiological correlates of empathy processing are reduced in BD depending on manic symptom severity.

Advanced Practice Registered Nurses: Gateway to Screening for Bipolar Disorder in Primary Care

Objective:

The goal of this mixed methods descriptive study was to explore Advanced Practice Registered Nurses’ (APRNs’) knowledge of bipolar disorder (BPD) and their perceptions of facilitators and barriers to screening patients with known depression for BPD.

Methods:

A mixed method study design using surveys on BPD knowledge and screening practices as well as focus group data collection method for facilitators and barriers to screening.

Results:

89 APRNs completed the survey and 12 APRNs participated in the focus groups. APRNs in any practice setting had low knowledge scores of BPD. No significant differences in screening for BPD for primary and non primary care APRNs. Qualitative findings revealed screening relates to tool availability; time, unsure of when to screen, fear of sigma, symptoms knowledge of BPD, accessible referral system, personal experiences with BPD, and therapeutic relationships with patients.

Conclusion:

Misdiagnosis of BPD as unipolar depression is common in primary care settings, leading to a long lag time to optimal diagnosis and treatment. The wait time to diagnosis and treatment could be reduced if APRNs in primary care settings screen patients with a diagnosis of depression by using validated screening tools. These results can inform APRN practice and further research on the effectiveness of screening for reducing the morbidity and mortality of BPDs in primary care settings; underscores the need for integration of mental health care into primary care as well as the need for more APRN education on the diagnosis and management of bipolar disorders.

Bipolar disorder

Bipolar disorder is a recurrent chronic disorder characterised by fluctuations in mood state and energy. It affects more than 1% of the world's population irrespective of nationality, ethnic origin, or socioeconomic status. Bipolar disorder is one of the main causes of disability among young people, leading to cognitive and functional impairment and raised mortality, particularly death by suicide. A high prevalence of psychiatric and medical comorbidities is typical in affected individuals. Accurate diagnosis of bipolar disorder is difficult in clinical practice because onset is most commonly a depressive episode and looks similar to unipolar depression. Moreover, there are currently no valid biomarkers for the disorder. Therefore, the role of clinical assessment remains key. Detection of hypomanic periods and longitudinal assessment are crucial to differentiate bipolar disorder from other conditions. Current knowledge of the evolving pharmacological and psychological strategies in bipolar disorder is of utmost importance.

Development of screening inventories for bipolar disorder at workplace: a diagnostic accuracy study

BACKGROUND

This study aimed to develop a new instrument for bipolar disorder screening, the Workplace Bipolar Inventory (WBI), and examine its efficiency as compared with Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) among workers on leave of the absence due to their mental health problems.

METHODS

Participants were recruited at a psychiatric outpatient clinic for return-to-work in Tokyo, Japan, during September to November 2009. 81 outpatients were recruited, 55 of whom (68%) agreed to participate in this study. Participants answered questionnaires including WBI, MDQ, BSDS, and demographic factors. Their diagnostic information according to the international statistical classification of diseases and related health problems 10th revision (ICD-10) was obtained from their attending psychiatrists. The WBI is a new self-rating 39-item questionnaire which developed with input from occupational mental health specialists and an analysis of WHO Composite International Diagnostic Interview (CIDI) items. The WBI contains 3 subtype scales: WBI-A (5 items), WBI-AB4 (9 items), and WBI-AB (39 items).

RESULTS

Reliability of these scales was moderate. In the AUC of these scales, BSDS was the best of them (0.83). In the optimal cut-off point of these scales, WBI-AB4 showed good efficiency of screening (sensitivity=0.78, specificity=0.75). Both MDQ and BSDS had high specificity, while low in sensitivity.

LIMITATIONS

The well validated diagnostic method (i.e., the structured clinical interview for DSM-IV [SCID] or CIDI) was not applied in this study.

CONCLUSIONS

The WBI, especially WBI-AB4 would be a useful workplace screening tool for workers with bipolar disorder.

Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study

Background

Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment.

Objective

The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful.

Methods

A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually.

Results

Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale—Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change—according to the Reliable Change Index—in self-rated symptoms of depression and perseverative thinking.

Conclusions

The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study.

Trial Registration

ClinicalTrials.gov NCT01742351; https://clinicaltrials.gov/ct2/show/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3).

Cost-of-illness studies for bipolar disorder: systematic review of international studies

BACKGROUND AND OBJECTIVES

Bipolar disorder (BD) may result in a greater burden than all forms of cancer, Alzheimer's disease and epilepsy. Cost-of-illness (COI) studies provide useful information on the economic burden that BD imposes on a society. Furthermore, COI studies are pivotal sources of evidence used in economic evaluations. This study aims to give a general overview of COI studies for BD and to discuss methodological issues that might potentially influence results. This study also aims to provide recommendations to improve practice in this area, based on the review.

METHODS

A search was performed to identify COI studies of BD. The following electronic databases were searched: MEDLINE, EMBASE, PsycInfo, Cochrane Database of Systematic Reviews, HMIC and openSIGLE. The primary outcome of this review was the annual cost per BD patient. A narrative assessment of key methodological issues was also included. Based on these findings, recommendations for good practice were drafted.

RESULTS

Fifty-four studies were included in this review. Because of the widespread methodological heterogeneity among included studies, no attempt has been made to pool results of different studies. Potential areas for methodological improvement were identified. These were: description of the disease and population, the approach to deal with comorbidities, reporting the rationale and impact for choosing different cost perspectives, and ways in which uncertainty is addressed.

CONCLUSIONS

This review showed that numerous COI studies have been conducted for BD since 1995. However, these studies employed varying methods, which limit the comparability of findings. The recommendations provided by this review can be used by those conducting COI studies and those critiquing them, to increase the credibility and reporting of study results.

Cost-effectiveness of lurasidone vs quetiapine extended-release (XR) in patients with bipolar depression

OBJECTIVE

Bipolar disorder imposes a high economic burden on patients and society. Lurasidone and quetiapine extended-release (XR) are atypical antipsychotic agents indicated for monotherapy treatment of bipolar depression. Lurasidone is also indicated as adjunctive therapy with lithium or valproate for depressive episodes associated with bipolar disorder. The objective of this analysis was to estimate the cost-effectiveness of lurasidone and quetiapine XR in patients with bipolar depression.

METHODS

A cost-effectiveness model was developed to compare lurasidone to quetiapine XR. The model was based on a US third-party payer perspective over a 3-month time horizon. The effectiveness measure in the model was the percentage of patients achieving remission (Montgomery-Åsberg Depression Rating Scale [MADRS] total score ≤12 by weeks 6-8). The comparison of remission rates was made through an adjusted indirect treatment comparison of lurasidone and quetiapine XR pivotal trials using placebo as the common comparator. Resource utilization for remission vs no remission was estimated from published expert panel data, and resource costs were obtained from a retrospective database study of bipolar I depression patients. Drug costs were estimated using the mean dose from clinical trials and wholesale acquisition costs.

RESULTS

Over the 3-month model time period, lurasidone and quetiapine XR patients, respectively, had similar mean numbers of emergency department visits (0.48 vs 0.50), inpatient days (2.1 vs 2.2), and office visits (9.3 vs 9.6). More lurasidone than quetiapine XR patients achieved remission (52.0% vs 43.2%) with slightly higher total costs ($4982 vs $4676), resulting in an incremental cost-effectiveness ratio of $3474 per remission. The probabilistic sensitivity analysis showed lurasidone had an 86% probability of being cost-effective compared to quetiapine XR at a willingness-to-pay threshold of $10,000 per remission.

CONCLUSIONS

Lurasidone may be a cost-effective option when compared to quetiapine XR for the treatment of adults with bipolar depression.

The prevalence and burden of bipolar depression

BACKGROUND

Bipolar disorder is characterized by debilitating episodes of depression and mood elevation (mania or hypomania). For most patients, depressive symptoms are more pervasive than mood elevation or mixed symptoms, and thus have been reported in individual studies to impose a greater burden on affected individuals, caregivers, and society. This article reviews and compiles the literature on the prevalence and burden of syndromal as well as subsyndromal presentations of depression in bipolar disorder patients.

METHODS

The PubMed database was searched for English-language articles using the search terms "bipolar disorder," "bipolar depression," "burden," "caregiver burden," "cost," "costs," "economic," "epidemiology," "prevalence," "quality of life," and "suicide." Search results were manually reviewed, and relevant studies were selected for inclusion as appropriate. Additional references were obtained manually from reviewing the reference lists of selected articles found by computerized search.

RESULTS

In aggregate, the findings support the predominance of depressive symptoms compared with mood elevation/mixed symptoms in the course of bipolar illness, and thus an overall greater burden in terms of economic costs, functioning, caregiver burden, and suicide.

LIMITATIONS

This review, although comprehensive, provides a study-wise aggregate (rather than a patient-wise meta-analytic) summary of the relevant literature on this topic.

CONCLUSION

In light of its pervasiveness and prevalence, more effective and aggressive treatments for bipolar depression are warranted to mitigate its profound impact upon individuals and society. Such studies could benefit by including metrics not only for mood outcomes, but also for illness burden.

In a double-blind, randomized and placebo-controlled trial, adjuvant allopurinol improved symptoms of mania in in-patients suffering from bipolar disorder

Allopurinol is a drug used primarily to treat hyperuricemia. In patients suffering from acute mania, increased levels of uric acid are observed, and symptom improvements are associated with decreased levels of uric acid. Accordingly, a purinergic dysfunction is plausibly a causative factor in the pathophysiology of mania. The aim of the present study was therefore to investigating whether allopurinol has benefits for patients treated with sodium valproate during acute mania. (Background) A double-blind, placebo-controlled study lasting 4 weeks was performed. The intention-to-treatment population included 57 patients; 50 concluded the study per protocol. Patients suffering from BPD and during acute mania were randomly assigned either to a treatment (sodium valproate 15-20 mg/kg+300 mg allopurinol twice a day) or to a control condition (sodium valproate 15-20 mg/kg+placebo). Experts rated illness severity and illness improvements (Clinical Global impression), and extent of mania via the Young Mania Rating scale. Uric acid levels were assessed at the beginning and end of the study. (Experimental procedures) Compared to the control group, symptoms of mania decreased significantly over time in the treatment group. Uric acid levels declined significantly in the treatment as compared to the control group. Probability of remission after 4 weeks was 23 times higher in the treatment than the control group. Lower uric acid levels after 4 weeks were associated with symptom improvements. (Results) The pattern of results from this double-blind, randomized and placebo-controlled study indicates that adjuvant allopurinol leads to significant improvements in patients suffering from acute mania (Conclusion).

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.

Prevalence, chronicity, burden and borders of bipolar disorder

Bipolar disorder (BD) has traditionally been thought of as an episodic condition, characterized by periods of hypomania/mania and depression. However, evidence is accumulating to suggest that this condition is associated with significant chronicity. For a large proportion of patients with BD, residual, sub-syndromal symptoms persist between major syndromal episodes, and studies have shown that many patients with bipolar disorder are symptomatic for approximately 50% of the time over follow-up periods of greater than 10 years. Moreover, while the prevalence of BD has been estimated to be around 1-2%, there is growing evidence that this may be a substantial underestimation. There are a number of reasons for this potential underestimation, including difficulties in diagnosis. Adding to the burden of BD is the issue of comorbidity, with an increased prevalence of many chronic conditions in those with a primary diagnosis of BD. Conversely, for many patients with chronic conditions, both medical and psychiatric, BD frequently exists as a comorbid secondary diagnosis. This issue of comorbidity complicates estimates of use of pharmaceutical agents for BD, such as mood stabilizers, which are known to be used off-label in conditions such as borderline personality or substance use disorder. We speculate that such off-label prescribing may not be truly off-label but may be instead fully justified by an overlooked secondary diagnosis of BD. Finally, we discuss the association of bipolar disorder with a significant economic burden, to the individual and to society, both due to the direct costs of medical expenditure and indirect costs such as loss of productivity and increased mortality.

Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data)

OBJECTIVE

Patients diagnosed with bipolar disorder (BD) are reported to have significant work impairment during interepisode intervals. This study was carried out to assess potential predictors of occupational disability in a longitudinal follow-up of euthymic patients.

METHOD

We included 327 euthymic patients diagnosed with BD type I or type II, 226 of whom were employed and 101 were receiving a severe disablement benefit (SDB). Sociodemographic data were studied and episode recurrence was assessed along a 1-year follow-up. Logistic regression analysis was applied to determine predictors of receiving SDB. Cox regression was built to study recurrences.

RESULTS

Predictors of receiving SDB were: axis II comorbidity [Odds Ratio (OR) = 2.94, CI: 1.26-6.86, P = 0.013], number of manic episodes (OR = 1.21, CI: 1.10-1.34, P < 0.001), being without stable partner (OR = 2.44, CI: 1.34-4.44, P = 0.004) and older age (OR = 1.08, CI: 1.05-1.12, P < 0.001). Bipolar patients receiving SDB presented more episodic recurrences regardless of polarity than employed bipolar patients (P = 0.002). The time until recurrence in 25% of the bipolar patients receiving SDB was 6.08 months (CI: 4.44-11.77) being 13.08 months (CI: 9.60 to -) in the employed group.

CONCLUSION

Occupational disability in bipolar patients is associated with axis II comorbidity, more previous manic episodes, not having a stable relationship, older age, and more recurrences at 1-year follow-up.

Diagnosing bipolar disorder in the community setting

BACKGROUND

Bipolar disorder (BD) is a common psychiatric illness. Diagnosing this condition is challenging, due to the frequent need to make the diagnosis based on historical symptoms, the lack of specificity of many of the symptoms, and the absence of accurate objective measures to confirm the diagnosis. A lack of consensus among psychiatrists as to the breadth of the diagnosis, increasing pressures to make a diagnosis quickly in clinical settings, and the availability of broader spectrum treatments have also served to foster uncertainty in diagnosis. This article examines the process of diagnosing BD, reviews factors that can confound the diagnostic process, and discusses how the sensitivity and specificity of the diagnosis can be improved.

METHODS

A MEDLINE search and a manual search of textbooks and abstracts from scientific meetings were conducted. Results were limited to publications in English, but no timeframe limitations were used.

RESULTS

The standard for diagnosing BD remains the psychiatric interview, with laboratory, genetic, radiographic, and neuroimaging tests still investigational, and psychological tests and questionnaires serving an ancillary role. The sensitivity and specificity of the BD diagnosis is less than optimal, with the condition being both overlooked and diagnosed when it is not present.

CONCLUSIONS

Factors leading to diagnostic uncertainty and approaches to improve the sensitivity and specificity of the BD diagnosis are discussed. A paradigm for differentiating between BD and borderline personality disorder is offered.

Treating bipolar disorder in the primary care setting: the role of aripiprazole

OBJECTIVE

The objective of this article is to present practical strategies for detecting and diagnosing bipolar disorder in the primary care setting and to review the evidence for the efficacy and safety of aripiprazole treatment for bipolar disorder.

DATA SOURCES

A review of the literature from 1980 to 2007 was conducted from November 2006 through February 2007 using a MEDLINE search and the key words bipolar disorder, primary care, detection, diagnosis, and aripiprazole.

STUDY SELECTION

A total of 100 articles that focused on the accurate detection and diagnosis of bipolar disorder and the evidence of the efficacy and safety of aripiprazole in the treatment of bipolar disorder were selected.

DATA SYNTHESIS

Patients with bipolar disorder often present to primary care physicians with depressive or mixed symptoms as opposed to purely hypomanic or manic symptoms. Accurate diagnosis of bipolar disorder is essential in order to provide timely and appropriate treatment. One treatment option available is aripiprazole, a partial agonist of dopamine (D)₂ and D₃ and serotonin (5-HT)(₁A) receptors and an antagonist of the 5-HT(₂A) receptor. Clinical trial data have shown aripiprazole to be effective in treating manic and mixed episodes associated with bipolar I disorder, both in the acute phase and over an extended period of treatment lasting from 6 months to 2 years.

CONCLUSIONS

Accurate diagnosis and treatment of bipolar disorder are challenges increasingly faced by primary care physicians. Strategies geared toward detection, diagnosis, and management of bipolar I disorder and other bipolar spectrum disorders may improve the treatment outcome for patients. Aripiprazole may be considered as another first-line choice for the treatment of bipolar I disorder; however, its utility in patients with bipolar spectrum disorders is yet to be determined.

Size and shape of the caudate nucleus in individuals with bipolar affective disorder

OBJECTIVE

The caudate nucleus (CN) is a crucial component of the ventral striatum, which is part of a prefrontal-striatal-thalamic circuit that is modulated by limbic structures to subserve emotional processing. Bipolar disorder is thought to be underpinned by dysfunctional anterior limbic networks, although MRI studies examining the CN have shown equivocal results. As gross volumetric analyses may not detect subtle regional change, we aimed to clarify the role of the CN in bipolar disorder by undertaking shape analysis to detect regional reductions.

METHODS

The CN was manually traced on MRI scans from 27 patients with bipolar-I disorder and 24 matched controls. A non-parametric spherical harmonic shape analysis was undertaken using the SPHARM toolkit.

RESULTS

Whilst the left CN volume was consistently larger in the sample, there was no effect of group or gender or significant interactions between these variables. Volume did not correlate with illness duration or lithium dosage, but was larger in those with a history of psychosis at trend level. However, left caudate shape differed significantly between groups, with deflation in an area along the ventromedial surface (connecting to dorsolateral prefrontal regions) in bipolar patients. Psychotic patients showed increases in the dorsal head and body at trend level overall, in regions connecting to medial and orbitofrontal regions.

CONCLUSIONS

These findings suggest that subtle rather than gross structural changes occur in the CN, which may not be detectable by volumetric analysis alone, and reflect alterations in specific frontostriatal circuitry in the disorder.

One-year psychosocial functioning in patients in the early vs. late stage of bipolar disorder

OBJECTIVE

The aim of this 1-year follow-up study was to compare functional outcome as well as clinical differences between patients with first- and multiple-episode bipolar disorder.

METHOD

Bipolar disorder patients with first (n = 60) and multiple episodes (n = 59) were recruited from two hospitals in Spain. The Functioning Assessment Short Test (FAST) was used to assess functioning. The Hamilton Depression Rating Scale (HAMD) and the Young Mania Rating Scale (YMRS) were administered to assess mood symptoms.

RESULTS

As expected, patients with first episode experienced a greater functioning compared to patients with multiple episodes (11.26 ± 10.94 vs. 26.91 ± 13.96; t = 6.436, P < 0.001). There were significant demographic and clinical differences between both groups. Baseline depressive symptoms (F = 9.553, df = 4, 102; P < 0.001) and age (F = 14.145, df = 4, 103; P < 0.001) were significantly associated with poor functional recovery at 6-month and 12-month assessment, respectively, in a group of patients with multiple episodes.

CONCLUSION

Our data give support to the model of staging in bipolar disorder, showing that the enduring neurotoxicity of repeated episodes may contribute to sustained impairment in multiple areas of psychosocial functioning.

Psychosocial and neurocognitive functioning in unipolar and bipolar depression: a 12-month prospective study

Previous studies have revealed psychosocial and cognitive impairments in patients during unipolar and bipolar depression, which persist even in subsyndromal and euthymic states. Currently, little is known about the nature and the extent of psychosocial and cognitive deficits during depression. The aim of the present study was to characterize psychosocial and cognitive profiles among unipolar (MDD) and bipolar (BD) patients during a major depressive episode and to compare the profiles of the patient groups. Depressed patients with MDD (n=13) and BD (n=11) were followed over a period of 12 months. Clinical, psychosocial and neuropsychological assessments were conducted at baseline and at 6-week, 4-month, 8-month and 12-month follow-ups. In the case of severe mood disorders, psychosocial and neurocognitive functioning seem similar among MDD and BD patients during a depressive episode. All MDD and BD patients had global psychosocial dysfunction, characterized by occupational and relational impairments. Furthermore, the neurocognitive profile was heterogeneous with regard to the nature and extent of cognitive deficits but attentional processes were frequently compromised. After 1 year of treatment, occupational and relational impairments, as well as neurocognitive dysfunction, persisted sufficiently to alter daily functioning.

Psychosocial and neurocognitive profiles in depressed patients with major depressive disorder and bipolar disorder

Previous studies have revealed psychosocial and cognitive impairments in patients during depression. The primary aim of this study was to investigate whether patients with major depression (MDD) and bipolar disorder (BD) differ in psychosocial and neurocognitive profiles. A second aim was to examine whether cognitive impairments are homogeneous among depressed patients. Patients with MDD (n=16) and BD (n=14) were enrolled during a major depressive episode. About half of them had comorbidities, including personality, substance use, and anxiety disorders. Information was collected about symptomatology and psychosocial functioning, whereas an exhaustive neuropsychological battery was administered to assess cognition. During a depressive episode, MDD and BD patients had global psychosocial dysfunction, characterized by occupational and relational impairments. A cognitive slowing was also observed, as well as deficits related to alertness, spontaneous flexibility, sustained and divided attention. Moreover, severity of depression and cognitive functions were significantly associated with psychosocial functioning. In the case of severe mood disorders, psychosocial and neurocognitive functioning seem similar among MDD and BD patients during a depressive episode. In addition to an altered daily functioning, the neurocognitive profile was heterogeneous with regard to the nature and extent of cognitive deficits. Executive functions, as well as verbal learning and memory, were preserved better than attentional processes.

Six-month functional outcome of a bipolar disorder cohort in the context of a specialized-care program

OBJECTIVES

A marked disparity between functional recovery and symptomatic improvement has been demonstrated in bipolar disorder. However, most of the previous studies have been conducted in the United States, and there is little prospective research from Europe on this topic. The main objective of the present six-month follow-up study was to assess functioning in a sample of Spanish bipolar disorder patients following an acute episode or subsyndromal state. Additionally, we also evaluated the sensitivity to change of the Functioning Assessment Short Test (FAST).

METHODS

A total of 97 bipolar disorder patients with syndromal (n = 59) or subsyndromal (n = 38) symptoms were evaluated using the 17-item Hamilton Depression Rating Scale and Young Mania Rating Scale. The FAST was the primary measure to assess multiple areas of psychosocial functioning. Functioning was evaluated at four different time periods: baseline, 21 days, three months, and six months.

RESULTS

A significant improvement in global functioning was found in the whole sample over the six-month period, as indicated by a reduction of FAST total score (mean ± standard deviation) from 39.97 ± 15.10 to 30.65 ± 16.93 (F = 36.104, p = 0.0001). This was also evident in all areas of functioning studied. However, only 26.4% of remitted patients (n = 42) achieved functional recovery, while 79.6% of the total sample (N = 97) experienced clinical remission of acute symptoms.

CONCLUSIONS

Although many patients presented syndromal recovery, only a minority of them achieved favorable functioning in multiple areas, even after specialized mental health care. Furthermore, the FAST scale was sensitive to detect minimal changes in functioning in both short (21 days) and long (6 months) periods, which may be relevant to the use of this scale in clinical trials.

Differences in demographic composition and in work, social, and functional limitations among the populations with unipolar depression and bipolar disorder: results from a nationally representative sample

Background

Existing literature on mood disorders suggests that the demographic distribution of bipolar disorder may differ from that of unipolar depression, and also that bipolar disorder may be especially disruptive to personal functioning. Yet, few studies have directly compared the populations with unipolar depressive and bipolar disorders, whether in terms of demographic characteristics or personal limitations. Furthermore, studies have generally examined work-related costs, without fully investigating the extensive personal limitations associated with diagnoses of specific mood disorders. The purpose of the present study is to compare, at a national level, the demographic characteristics, work productivity, and personal limitations among individuals diagnosed with bipolar disorder versus those diagnosed with unipolar depressive disorders and no mood disorder.

Methods

The Medical Expenditure Panel Survey 2004-2006, a nationally representative survey of the civilian, non-institutionalized U.S. population, was used to identify individuals diagnosed with bipolar disorder and unipolar depressive disorders based on ICD-9 classifications. Outcomes of interest were indirect costs, including work productivity and personal limitations.

Results

Compared to those with depression and no mood disorder, higher proportions of the population with bipolar disorder were poor, living alone, and not married. Also, the bipolar disorder population had higher rates of unemployment and social, cognitive, work, and household limitations than the depressed population. In multivariate models, patients with bipolar disorder or depression were more likely to be unemployed, miss work, and have social, cognitive, physical, and household limitations than those with no mood disorder. Notably, findings indicated particularly high costs for bipolar disorder, even beyond depression, with especially large differences in odds ratios for non-employment (4.6 for bipolar disorder versus 1.9 for depression, with differences varying by gender), social limitations (5.17 versus 2.85), cognitive limitations (10.78 versus 3.97), and work limitations (6.71 versus 3.19).

Conclusion

The bipolar disorder population is distinctly more vulnerable than the population with depressive disorder, with evidence of fewer personal resources, lower work productivity, and greater personal limitations. More systematic analysis of the availability and quality of care for patients with bipolar disorder is encouraged to identify effectively tailored treatment interventions and maximize cost containment.

An epidemiologic and clinical overview of medical and psychopathological comorbidities in major psychoses

The presence of comorbidity in major psychoses (e.g., schizophrenia and psychotic subtypes of bipolar disorder and major depressive disorder) seems to be the rule rather than the exception in both DSM-IV and ICD-10. Examining comorbidity in major psychoses, however, requires an investigation into the different levels of comorbidity (either full-blown and subsyndromal) which should be analyzed in both psychopathological and medical fields. On one hand, the high prevalence of psychiatric comorbidity in major psychoses may be the result of the current nosographic systems. On the other hand, it may stem from a common neurobiological substrate. In fact, comorbid psychopathological conditions may share a biological vulnerability, given that dysfunction in specific brain areas may be responsible for different symptoms and syndromes. The high rates of comorbidity in major psychoses require targeted pharmacological treatments in order to effectively act on both the primary diagnosis and comorbid conditions. Nevertheless, few controlled trials in comorbid major psychoses had been carried out and treatment recommendations in this field have mostly an empirical basis. The aim of the present article is to provide a comprehensive and updated overview in relation to epidemiological and clinical issues of comorbidity in major psychoses.

Economic impact to employers of treatment options for cardiac arrhythmias in the US health system

OBJECTIVE

To measure relative employer-sponsored postablation costs for cardiac arrhythmias (CA), specifically atrial fibrillation (AF).

METHODS

Regression-Controlled Employee/Spouse Database study (2001 to 2008) comparing CA patients with and without ablation and AF patients with and without ablation. Regression-adjusted monthly medical, pharmacy, sick leave, and short-term disability costs were calculated 11 months before index to 36 months after index (first ablation date or average date for nonablation patients). Relative pre/postindex comparisons between ablation and nonablation cohorts were calculated and time until ablation procedure cost recovery extrapolated.

RESULTS

Few CA (280 of 11,291; 2.48%) and AF (93 of 3062; 3.04%) patients received ablation. Ablation cohorts cost less than nonablation cohorts postablation. Estimated total ablation-period costs were recovered 38 to 50 months postablation, including employee absence payment recovery within 18 months.

CONCLUSION

Current ablation use in employer-sponsored health plans may improve health care and absence costs over time.

Surgical treatment of morbid obesity among patients with bipolar disorder: a research agenda

INTRODUCTION

Persons with bipolar disorder (BD) have an increased risk of obesity and associated diseases. Success of current behavioral treatment for obesity in patients with BD is inadequate.

METHODS

Existing literature on bariatric surgery outcomes in populations with BD were reviewed, and needed areas of research were identified.

RESULTS

Knowledge about bariatric surgery outcomes among patients with BD is limited. Available evidence indicates that bariatric surgery is a uniquely effective intervention for achieving and sustaining significant weight loss and improving metabolic parameters. Notwithstanding the benefits of bariatric surgery in nonpsychiatric samples, individuals with BD (and other serious and persistent mental illnesses) have decreased access to this intervention. Areas of needed research include: (1) current practice patterns; (2) metabolic course after bariatric surgery; (3) psychiatric course after bariatric surgery; and (4) mechanisms of psychiatric effect.

CONCLUSION

The considerable hazards posed by obesity in BD, as measured by illness complexity and premature mortality, provide the basis for hypothesizing that bariatric surgery may prevent and improve morbidity in this patient population. In addition to physical health benefits, bariatric surgery may exert a robust and favorable effect on the course and outcome of BD and reduce obesity-associated morbidity, the most frequent cause of premature mortality in this patient population.

Comparing costs and absences for multiple sclerosis among US employees: pre- and post-treatment initiation

BACKGROUND

Limited data exist on the effects of Disease Modifying Treatments (DMTs) on direct and indirect costs among employees treated for Multiple Sclerosis (MS). The objective was to compare costs and absences among employees treated with DMTs (e.g., interferons [IFNs]: IFN-β1a-IM = Avonex = 'A', IFN-β1b = Betaseron = 'B', IFN-β1a-SC = Rebif = 'R', or glatiramer acetate = Copaxone = 'C') for MS pre and post therapy initiation.

METHODS

A healthcare claims database of US employees (2001-2008) was used to identify patients with two or more DMT prescriptions or one DMT prescription with a MS diagnosis (ICD-9 = 340.X) who were continuously employed and with health plan coverage 6 months pre and post DMT initialization. Outcome measures included: direct costs; indirect costs and absences associated with sick leave (SL) and short-term disability (STD); and medical costs and utilization by place of service (POS). All costs are inflation-adjusted to 2010 US$. Between- and within-group outcomes were compared using Student's t-tests for continuous and chi-square tests for discrete variables and considered significant when P ≤ 0.05.

RESULTS

Overall, 153 eligible employees were identified: 'A' = 68, 'B' = 22, 'R' = 21, 'C' = 42; 76 employees had SL eligibility; 89 had STD eligibility; and 97 employees had POS indicators. Following treatment initiation, healthcare costs decreased significantly for 'A' users (-53.8%, -$3084) and 'B' users (-67.1%, -$4103), while SL costs only decreased significantly for 'A' users (-60.5%, -$704); changes in SL absence days for 'A' and 'B' users were significantly lower than for 'C' users (both P < 0.05). In the POS sample, total medical costs significantly decreased for 'A' (-$3643), 'B' (-$3470), and 'C' (-$3762), while 'R' increased ($2093) non-significantly. Only 'A' users had significant proportion-of-care reductions (Emergency Department, Outpatient Hospital, and 'Other' locations).

CONCLUSION

Among MS employees treated with DMTs in the real-world, 'A' and 'B' users had significantly greater reductions in SL costs post therapy initiation compared with 'C' and 'R'. Only 'A' users showed a significant reduction in SL absence days, while the other cohorts reported increases.

LIMITATIONS

Small sample sizes may limit the interpretability of these results.