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

OBJECTIVE

To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) as an adjunct to standard care from an Australian health sector perspective, compared to standard care alone for adults with treatment-resistant bipolar depression (TRBD).

METHODS

An economic model was developed to estimate the cost per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained for rTMS added to standard care compared to standard care alone, for adults with TRBD. The model simulated the time in three health states (mania, depression, residual) over one year. Response to rTMS was sourced from a meta-analysis, converted to a relative risk and used to modify the time in the depressed state. Uncertainty and sensitivity tested the robustness of results.

RESULTS

Base-case incremental cost-effectiveness ratios (ICERs) were $72,299 per DALY averted (95 % Uncertainty Interval (UI): $60,915 to $86,668) and $46,623 per QALY gained (95 % UI: $39,676 - $55,161). At a willingness to pay (WTP) threshold of $96,000 per DALY averted, the base-case had a 100 % probability of being marginally cost-effective. At a WTP threshold of $64,000 per QALY gained, the base-case had a 100 % probability of being cost-effective. Sensitivity analyses decreasing the number of sessions provided, increasing the disability weight or the time spent in the depression state for standard care improved the ICERs for rTMS.

CONCLUSIONS

Dependent on the outcome measure utilised and assumptions, rTMS would be considered a very cost-effective or marginally cost-effective adjunct to standard care for TRBD compared to standard care alone.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees

IMPORTANCE

Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population.

OBJECTIVE

To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020.

EXPOSURES

Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014.

MAIN OUTCOMES AND MEASURES

Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes.

RESULTS

The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008).

CONCLUSIONS AND RELEVANCE

This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.

Adverse stroke outcomes among patients with bipolar disorder

Failure to deliver the standard stroke care is suspected to be a potential reason for disproportionately high mortality among patients with co-morbid bipolar disorder (BD). Few studies have explored adverse outcomes and medical care costs concurrently (as a proxy for care intensity) among patients with BD admitted for stroke. Data for this nationwide population-based study were extracted from the Taiwan National Health Insurance Research Database, on 580 patients with BD hospitalized for stroke (the study group) and a comparison group consisting of randomly selected 1740 stroke patients without BD matched by propensity scores. Conditional logistic regression was used to estimate odds ratios (OR) for adverse in-hospital outcomes between study group and comparison group. We found that stroke patients with BD had significantly lower in-hospital mortality (3.28% vs. 5.63%), acute respiratory failure (2.59% vs. 5.57%), and use of mechanical ventilation (6.55% vs. 10.23%) than the comparison group. After adjusting for geographical location, urbanization level, monthly income, hypertension, diabetes, hyperlipidemia, and coronary heart disease, the odds of in-hospital mortality, acute respiratory failure, and use of mechanical ventilation in the BD group were 0.56 (95% CI: 0.34–0.92), 0.46 (95% CI: 0.26–0.80), and 0.63 (95% CI: 0.44–0.91), respectively. No differences were found in hospitalization costs and the length of hospital stay. With comparable hospitalization costs and length of hospital stay, we concluded that stroke patients with BD had lower in-hospital mortality and serious adverse events compared to stroke patients without BD.

Health Care Resource Use, Costs, and Diagnosis Patterns in Patients With Schizophrenia and Bipolar Disorder: Real-world Evidence From US Claims Databases

PURPOSE

Schizophrenia (SCZ) and bipolar disorder (BD) are typically viewed as nonconcurrent psychiatric disorders, yet patients may experience mood and SCZ symptoms simultaneously. Several studies have shown overlap between SCZ and BD symptoms and susceptibility genes. This study explored the following: (1) patterns of administrative claims; (2) demographic characteristics and comorbidities; (3) health care resource use; and (4) health care costs in patients with diagnoses of SCZ, type I BD (BD-I), and both in a real-world setting.

METHODS

This study was a retrospective cohort trial using 4.5years (January 1, 2012-June 30, 2016) of Truven MarketScan commercial, Medicaid, and Medicare supplemental databases. We considered a patient to have a new episode of SCZ if he or she had 1 inpatient claim or 2 outpatient claims for SCZ within the identification period (January 1, 2013-June 30, 2015). BD-I was defined in an analogous way. Three study cohorts were defined: (1) SCZ alone (cohort I), met the claims-based diagnostic criteria for SCZ; (2) BD-I alone (cohort II), met the claims-based diagnostic criteria for BD-I; and (3) BD-I and SCZ (cohort III), met the claims-based diagnostic criteria for both SCZ and BD-I.

FINDINGS

Of the 63,725 patients in the final sample, 11.5% (n = 7336) had a new episode of SCZ alone (cohort I), 80.8% (n = 51,480) had a new episode of BD-I alone (cohort II), and 7.7% (n = 4909) had new episodes of both SCZ and BD-I (cohort III). Considering cohort III, 18.8% (n = 927) received both diagnoses on the same day. In the year after diagnosis, the cohort having a diagnosis of both SCZ and BD-I (cohort III) had the highest all-cause hospitalization rates (67.4% vs 39.5% in SCZ alone and 33.7% in BD-I alone) and the highest mean (SD) number of emergency department visits (3.44 [7.1] vs 1.39 [3.5] in SCZ alone and 1.29 [3.2] in BD-I alone). All-cause total health care costs were highest in the cohort having a diagnosis of both SCZ and BD-I (mean [SD]), $51,085 [$62,759]), followed by the SCZ alone cohort ($34,204 [$52,995]), and the BD-I alone cohort ($26,396 [$48,294]).

IMPLICATIONS

Our analyses indicate that a substantial number of patients received diagnoses of both SCZ and BD-I, based on claims, in a 2.5-year period. Patients with a diagnosis of both SCZ and BD-I had higher health care utilization and costs than patients with either diagnosis alone. We identified differential patient characteristics, utilization of medications and health care services, and health care costs among the cohorts.

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

PURPOSE

The aim of this study is to explore the amount of OOP health expenditures and their determinants in patients with bipolar disorder, anxiety, schizophrenia and other psychotic disorders in a psychiatry outpatient clinic of Turkey.

METHODS

The study group was 191 patients who attended to the Psychiatry Outpatient Clinic in June 2014. All patients were previously diagnosed with either 'bipolar disorder', 'anxiety disorder' or 'schizophrenia and other psychotic disorders'. The dependent variable was OOP expenditures for prescription, medical tests and examinations. Independent variables were age, gender, education, occupation, existence of social and/or private health insurance, equivalent household income and the financial resources. Student's t test, Mann-Whitney U test, ANOVA and logistic regression methods were applied with SPSS 15.0 for analysis.

RESULTS

OOP expenditures per admission were higher in patients with schizophrenia and other psychotic disorders ($8.4) than those with anxiety disorders ($4.8) (p = 0.02). OOP expenditures were higher in patients paying with debit ($9.8) than paying with monthly income ($6.2) (p = 0.04). OOP expenditures were higher in patients without social health insurance ($45.8) than others ($4.8) (p = 0.003). There was not a difference in OOP expenditures with respect to equivalent household income level, occupational class or education level of the patients (respectively p: 0.90, p: 0.09, p: 0.52).

CONCLUSIONS

Patients who were diagnosed with 'schizophrenia and other psychotic disorders' were disadvantaged in paying significantly higher amounts for their treatment. A substantial group of these patients compulsorily payed with debit. Considering this financial burden, diagnosis of the patient should be prioritized in health insurance coverage.

Remote mood monitoring for adults with bipolar disorder: An explorative study of compliance and impact on mental health service use and costs

BACKGROUND

Remote monitoring of mood disorders may be an effective and low resource option for patient follow-up, but relevant evidence remains very limited. This study explores real-life compliance and health services impacts of mood monitoring among patients with bipolar disorder in the UK.

METHODS

Patients with a diagnosis of bipolar disorder who were registered users of the True Colours monitoring system for at least 12months at study assessment were included in this retrospective cohort study (n=79). Compliance was measured as the proportion of valid depression and mania scale messages received in comparison to their expected numbers over the first 12months of monitoring. Mental health service use data were extracted from case notes, costed using national unit costs, and compared 12months before (pre-TC period) and 12months after (TC period) patients' engagement with monitoring. Associations with relevant patient factors were investigated in a multiple regression model.

RESULTS

Average compliance with monitoring was 82%. Significant increases in the annual use and costs of psychiatrist contacts and total mental health services were shown for patients newly referred to the clinic during the pre-TC period but not for long-term patients of the clinic. Psychiatric medication costs increased significantly between the pre-TC and TC periods (£235, P=0.005) unrelated to patients' referral status.

CONCLUSIONS

Remote mood monitoring has good compliance among consenting patients with bipolar disorder. We found no associations between observed changes in mental health service costs and the introduction of monitoring except for the increase in psychiatric medication costs.

A Systematic Review and Critical Appraisal of Economic Evaluations of Pharmacological Interventions for People with Bipolar Disorder

BACKGROUND

Bipolar disorder (BD) is a chronic mood disorder that causes substantial psychological and financial burden. Various pharmacological treatments are effective in the management and prevention of acute episodes of BD. In an era of tighter healthcare budgets and a need for more efficient use of resources, several economic evaluations have evaluated the cost effectiveness of treatments for BD.

OBJECTIVE

The aim of this study was to systematically review and appraise published economic evaluations of pharmacological interventions for BD.

METHODS

A systematic search combining search terms specific to BD with a health economics search filter was conducted on six bibliographic databases (EMBASE, MEDLINE, PsycINFO, HTA, NHS EED, CENTRAL) in order to identify trial- or model-based full economic evaluations of pharmacological treatments of any phase of the disorder that were published between 1 January 1990 and 18 December 2015. Studies that met the inclusion criteria were critically appraised using the Quality of Health Economic Studies (QHES) checklist, and synthesised in a narrative way.

RESULTS

The review included 19 economic studies, which varied with regard to the type and number of interventions assessed, the study design, the phase of treatment (acute or maintenance), the source of efficacy data and the method for evidence synthesis, the outcome measures, the time horizon and the countries/settings in which the studies were conducted. The study quality was variable but the majority of studies were of high or fair quality.

CONCLUSION

Pharmacological interventions are cost effective, compared with no treatment, in the management of BD, both in the acute and maintenance phases. However, it is difficult to draw safe conclusions on the relative cost effectiveness between drugs due to differences across studies and limitations characterising many of them. Future economic evaluations need to consider the whole range of treatment options available for the management of BD and adopt appropriate methods for evidence synthesis and economic modelling, to explore more robustly the relative cost effectiveness of pharmacological interventions for people with BD.

Scaling-up essential neuropsychiatric services in Ethiopia: a cost-effectiveness analysis

INTRODUCTION

There is an immense need for scaling-up neuropsychiatric care in low-income countries. Contextualized cost-effectiveness analyses (CEAs) provide relevant information for local policies. The aim of this study is to perform a contextualized CEA of neuropsychiatric interventions in Ethiopia and to illustrate expected population health and budget impacts across neuropsychiatric disorders.

METHODS

A mathematical population model (PopMod) was used to estimate intervention costs and effectiveness. Existing variables from a previous WHO-CHOICE regional CEA model were substantially revised. Treatments for depression, schizophrenia, bipolar disorder and epilepsy were analysed. The best available local data on epidemiology, intervention efficacy, current and target coverage, resource prices and salaries were used. Data were obtained from expert opinion, local hospital information systems, the Ministry of Health and literature reviews.

RESULTS

Treatment of epilepsy with a first generation antiepileptic drug is the most cost-effective treatment (US$ 321 per DALY adverted). Treatments for depression have mid-range values compared with other interventions (US$ 457-1026 per DALY adverted). Treatments for schizophrenia and bipolar disorders are least cost-effective (US$ 1168-3739 per DALY adverted).

CONCLUSION

This analysis gives the Ethiopian government a comprehensive overview of the expected costs, effectiveness and cost-effectiveness of introducing basic neuropsychiatric interventions.

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.

Impact of initiation of asenapine on patterns of utilization and cost of healthcare resources associated with the treatment of bipolar I disorder

OBJECTIVE

To assess the impact of initiation of asenapine on "real-world" levels of utilization and cost of healthcare services for the treatment of bipolar I disorder (BPD) in the US.

METHODS

Using two large US healthcare claims databases that collectively included commercially insured patients aged < 65 years and Medicare enrollees, this study identified all adults (≥ 18 years) with evidence of BPD who began therapy with asenapine between 2009-2012. The date of the earliest claim for asenapine during this period was deemed the 'index date', and patients without continuous enrollment for the 6-month periods before and after this date were excluded ('pre-index' and 'post-index', respectively). Healthcare claims with a BPD diagnosis, plus psychiatric medications and the costs thereof (2012 dollars) were deemed 'BPD-related'. Differences in BPD-related utilization and cost of healthcare services were compared between the pre- and post-index periods.

RESULTS

A total of 1403 patients met all selection criteria; the mean age was 42.8 years and 70.6% were women. Relative to pre-index, significant decreases were noted in post-index use of BPD-related healthcare services, most notably admissions (from 24.0% to 12.3% during the post-index period) and emergency department visits (from 4.6% to 2.6%) (both p < 0.05). While pharmacy costs increased, mean total post-index BPD-related healthcare costs were $979 lower than pre-index ($5002 vs $5981; p < 0.05), primarily due to the decrease in BPD-related admissions.

CONCLUSIONS

Relative to the 6-month period beforehand, levels of utilization of BPD-related healthcare services and costs decreased during the 6-month period immediately following initiation of asenapine therapy.

The need for cost-effective choices to treat patients with bipolar 1 disorders including asenapine

BACKGROUND

Bipolar 1 disorders (BPD) are a chronic disorder with prevalence rates of up to 2.6% of the adult population or higher and appreciable direct and indirect costs. As a result, these are a concern to health authorities especially given the low age of onset. Consequently, there is a need to treat BPD patients well and improve their quality-of-life. Pharmacotherapy includes mood stabilizers and atypical antipsychotics (AAPs). AAPs have different mechanisms of action and side-effects, so treatment needs to be tailored. Asenapine in clinical trials is as effective as olanzapine, with less metabolic side-effects.

METHODS

Chitnis and colleagues assessed the cost-effectiveness of asenapine among patients in healthcare databases.

RESULTS AND CONCLUSION

They showed in routine care that asenapine also reduces hospital and emergency room admissions, making it cost neutral in BPD, which is of interest to health authorities and clinicians.

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.

Is research on borderline personality disorder underfunded by the National Institute of Health?

The relationship between bipolar disorder and borderline personality disorder has generated intense interest. Similar to patients with bipolar disorder, patients with borderline personality disorder are frequently hospitalized, are chronically unemployed, abuse substances, attempt and commit suicide. However, one significant difference between the two disorders is that patients with borderline personality disorder are often viewed negatively by mental health professionals. In the present paper we examined whether this negative bias against borderline personality disorder might be reflected in the level of research funding on the disorder. We searched the National Institute of Health (NIH) Research Portfolio Online Portfolio Reporting Tool (RePORT) for the past 25 years and compared the number of grants funded and the total amount of funding for borderline personality disorder and bipolar disorder. The yearly mean number of grants receiving funding was significantly higher for bipolar disorder than for borderline personality disorder. Results were the same when focusing on newly funded grants. For every year since 1990 more grants were funded for bipolar disorder than borderline personality disorder. Summed across all 25 years, the level of funding for bipolar disorder was more than 10 times greater than the level of funding for borderline personality disorder ($622 million vs. $55 million). These findings suggest that the level of NIH research funding for borderline personality disorder is not commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder.

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

BACKGROUND

Schizophrenia and bipolar disorder (BD) are psychiatric diseases that are commonly managed with antipsychotics. Treatment pathways are highly variable and no universal treatment guidelines are available. The primary objective of the Italian Burden of Illness in Schizophrenia and BD (IBIS) study was to describe pharmaco-utilisation of antipsychotic treatments and characteristics of patients affected by schizophrenia or BD. A secondary objective was to describe costs of illness for patients with schizophrenia or BD.

METHODS

IBIS was a multicentre, real-world, retrospective, observational cohort study based on data obtained from administrative databases of 16 Local Health Units in Italy (~7.5 million individuals). Patients with schizophrenia or BD ≥18 years of age treated with antipsychotics between 1 January 2008 and 31 December 2009 were included in the primary analysis. Pharmaco-utilisation data were gathered over a follow-up period of 12 months.

RESULTS

Patients with schizophrenia and BD received a wide variety of antipsychotic medications. The proportion of patients on antipsychotic monotherapy was 68% in patients with schizophrenia and 70% in patients with BD. In patients with schizophrenia, ~1/3 of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants (34.7%) compared with over half of those on antipsychotic polytherapy (52.2%). In patients with BD, use of mood stabilisers and/or antidepressants was even higher; 76.9% of patients receiving antipsychotic monotherapy also received mood stabilisers and/or antidepressants compared with 85.5% of patients on antipsychotic polytherapy. Switch therapy was more frequent in patients with BD than in patients with schizophrenia, whereas add-on therapy was more frequent in patients with schizophrenia than in patients with BD. The mean total disease-related cost per patient per annum was higher in patients with schizophrenia (€4,157) than in patients with BD (€3,301). The number and cost of hospitalisations was higher in patients with BD, whereas the number and cost of nursing home stays was higher in patients with schizophrenia.

CONCLUSION

Use of administrative databases has permitted retrieval of comprehensive information about therapeutic pathways, diagnostic history and costs in patients affected by schizophrenia or BD. A need for personalised treatment pathways has been described.

TRIAL REGISTRATION

clinicaltrials.gov: NCT01392482 ; first received June 29, 2011.

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

OBJECTIVE

This study investigates the healthcare costs of adverse events (AE) associated with treatment of bipolar disorder with two atypical oral antipsychotics (AOA): aripiprazole (ARI) and olanzapine (OLA).

METHODS

A cost analysis using a Markov model considering the following health states was performed: no existence of adverse events (NAE); extrapyramidal symptoms (EPS); weight gain (WG); and sexual dysfunction (SD). Transition probabilities amongst health states were estimated from meta-analyses of clinical trials and from a retrospective Spanish study. The healthcare costs associated to each health state were obtained from a published Spanish study. The minimum acquisition cost per mg of the mean daily dose for each AOA was used. This is considered to be a relevant efficiency criterion in Hospital Pharmacy Departments. The time horizon applied in the analysis was 12 months. A probabilistic sensitivity analysis was performed for all the variables involved in the analysis with Monte Carlo simulations. All costs were updated to 2013 costs using the Spanish Health System price index.

RESULTS

In comparison with OLA, treatment with ARI generates annual average cost savings per patient of ¤289 (CI95% ¤271; ¤308). In the hypothetical scenario in which we assume that ARI may have a similar rate of sexual dysfunction as that of quetiapine (i.e. the lowest rate amongst AOAs), the additional cost per patient would be ¤323 (CI95% ¤330; ¤317).

CONCLUSION

The results of this analysis show that patients treated with aripiprazole demonstrate lower adverse events costs in comparison to olanzapine. This difference may generate significant cost savings in the Spanish health system in the treatment of patients affected by bipolar disorders. The robustness of the results was tested via a probabilistic analysis.

A systematic and critical review of model-based economic evaluations of pharmacotherapeutics in patients with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a chronic and relapsing mental illness with a considerable health-related and economic burden. The primary goal of pharmacotherapeutics for BD is to improve patients' well-being. The use of decision-analytic models is key in assessing the added value of the pharmacotherapeutics aimed at treating the illness, but concerns have been expressed about the appropriateness of different modelling techniques and about the transparency in the reporting of economic evaluations.

OBJECTIVES

This paper aimed to identify and critically appraise published model-based economic evaluations of pharmacotherapeutics in BD patients.

METHODS

A systematic review combining common terms for BD and economic evaluation was conducted in MEDLINE, EMBASE, PSYCINFO and ECONLIT. Studies identified were summarised and critically appraised in terms of the use of modelling technique, model structure and data sources. Considering the prognosis and management of BD, the possible benefits and limitations of each modelling technique are discussed.

RESULTS

Fourteen studies were identified using model-based economic evaluations of pharmacotherapeutics in BD patients. Of these 14 studies, nine used Markov, three used discrete-event simulation (DES) and two used decision-tree models. Most of the studies (n = 11) did not include the rationale for the choice of modelling technique undertaken. Half of the studies did not include the risk of mortality. Surprisingly, no study considered the risk of having a mixed bipolar episode.

CONCLUSIONS

This review identified various modelling issues that could potentially reduce the comparability of one pharmacotherapeutic intervention with another. Better use and reporting of the modelling techniques in the future studies are essential. DES modelling appears to be a flexible and comprehensive technique for evaluating the comparability of BD treatment options because of its greater flexibility of depicting the disease progression over time. However, depending on the research question, modelling techniques other than DES might also be appropriate in some cases.

Cost-effectiveness of asenapine in the treatment of bipolar I disorder patients with mixed episodes

OBJECTIVE

Around one-third of patients with bipolar I disorder (BD-I) experience mixed episodes, characterized by both mania and depression, which tend to be more difficult and costly to treat. Atypical antipsychotics are recommended for the treatment of mixed episodes, although evidence of their efficacy, tolerability, and cost in these patients is limited. This study evaluates, from a UK National Health Service perspective, the cost-effectiveness of asenapine vs olanzapine in BD-I patients with mixed episodes.

METHODS

Cost-effectiveness was assessed using a Markov model. Efficacy was informed by a post-hoc analysis of two short-term clinical trials, with response measured as a composite Young Mania Rating Score and Montgomery-Åsberg Depression Rating Scale end-point. Probabilities of discontinuation and relapse to manic, mixed, and depressive episodes were sourced from published meta-analyses. Direct costs (2012-2013 values) included drug acquisition, monitoring, and resource use related to bipolar disorder as well as selected adverse events. Benefits were measured as quality-adjusted life years (QALYs).

RESULTS

For treating mixed episodes, asenapine generated 0.0187 more QALYs for an additional cost of £24 compared to olanzapine over a 5-year period, corresponding to a £1302 incremental cost-effectiveness ratio. The higher acquisition cost of asenapine was roughly offset by the healthcare savings conferred through its greater efficacy in treating these patients. The model shows that benefits were driven by earlier response to asenapine during acute treatment and were maintained during longer-term follow-up. RESULTS were sensitive to changes in key parameters including short and longer-term efficacy, unit cost, and utilities, but conclusions remained relatively robust.

CONCLUSIONS

RESULTS suggest that asenapine is a cost-effective alternative to olanzapine in mixed episode BD-I patients, and may have specific advantages in this population, potentially leading to healthcare sector savings and improved outcomes. Limitations of the analysis stem from gaps in clinical and economic evidence for these patients and should be addressed by future clinical trials.

Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid

OBJECTIVES

To measure the impact of state Medicaid formulary policies on costs for patients with schizophrenia and bipolar disorder.

STUDY DESIGN

Retrospective analysis of medical and pharmacy claims for patients diagnosed with schizophrenia or bipolar disorder in 24 state Medicaid programs.

METHODS

We combined information on formulary restrictions in Medicaid with the medical and pharmacy claims of 117,908 patients with schizophrenia and 170,596 patients with bipolar disorder in Medicaid who were single-eligible, and newly prescribed a second-generation antipsychotic from 2001 to 2008. We tested the impact of formulary restrictions on the medical costs and utilization of patients in the 12 months after the index prescription. To capture social costs in addition to medical expenditures in Medicaid, we estimated the incremental costs of incarcerating patients with schizophrenia and bipolar disorder associated with formulary restrictions.

RESULTS

Patients with schizophrenia subject to formulary restrictions were more likely to be hospitalized (odds ratio 1.13, P <.001), had 23% higher inpatient costs (P <.001), and 16% higher total costs (P <.001). Similar effects were observed for patients with bipolar disorder. Our estimates suggest restrictive formulary policies in Medicaid increased the number of prisoners by 9920 and incarceration costs by $362 million nationwide in 2008.

CONCLUSIONS

Applying formulary restrictions to atypical antipsychotics is associated with higher total medical expenditures for patients with schizophrenia and bipolar disorder in Medicaid. Combined with the other social costs such as an increase in incarceration rates, these formulary restrictions could increase state costs by $1 billion annually, enough to offset any savings in pharmacy costs.

Acute inpatient treatment, hospitalization course and direct costs in bipolar patients with intellectual disability

To explore the impacts of intellectual disability (ID) on psychotropic medication use, length of hospital stay (LOS) and direct hospitalization costs during inpatient treatment for acute bipolar episodes, all 17,899 index hospitalizations due to acute bipolar episodes between 1998 and 2007 in Taiwan were identified from a total population health insurance claims database, amongst which 544 subjects had a concomitant diagnosis of ID. Pattern of psychotropic medication use, LOS, discharge outcome and direct costs during hospitalization were compared between bipolar patients with ID and without ID and multivariate models controlling for major cost confounders were used to explore the impacts of ID on LOS, discharge outcome and inpatient costs. The results indicated that, compared to bipolar patients without ID, bipolar patients with ID were younger, had longer LOS and received significantly lower daily equivalent dosages of antipsychotics, mood stabilizers, lithium and benzodiazepines. Significantly more bipolar patients with ID could not be discharged successfully. The longer LOS possibly reflected slower clinical stabilization, conservative use of medications and difficulty in community placement. The lower average daily reimbursements indicated that treatment of bipolar patients with ID were under-funded, whereas the higher total direct costs resulting from prolonged LOS placed greater economic straint on healthcare system. The findings support that bipolar patients with ID are clinically unique but relatively under-supported during acute hospitalization. Modifying current pharmacological intervention, health care resources allocation and community supporting structure is paramount to reducing LOS and improving hospitalization outcome.

Aripiprazole for the treatment and prevention of acute manic and mixed episodes in bipolar I disorder in children and adolescents: a NICE single technology appraisal

As part of its single technology process, the National Institute for Health and Care Excellence (NICE) invited the manufacturers of aripiprazole (Otsuka Pharmaceutical Co. and Bristol Myers Squibb) to submit evidence of the clinical and cost effectiveness of aripiprazole for the treatment and prevention of acute manic and mixed episodes in bipolar I disorder in children and adolescents. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG). The ERG produced a critical review of the evidence for the clinical and cost effectiveness of the technology, based upon the manufacturers' submission to NICE. The evidence, which was derived mainly from a double-blind, phase III, placebo-controlled trial of aripiprazole in patients aged 10-17 years, showed that aripiprazole performed significantly better than placebo in reducing mania according to the primary outcome measurement (the Young Mania Rating Scale at 4 weeks). Safety outcomes indicated that aripiprazole was significantly more likely to cause extrapyramidal symptoms and somnolence than placebo. The manufacturers also presented a network meta-analysis of aripiprazole versus other atypical antipsychotics commonly used to treat manic episodes (olanzapine, quetiapine and risperidone) to show that aripiprazole performed similarly to the comparator drugs in terms of efficacy and safety. Aripiprazole was demonstrated to perform better in safety outcomes of (1) less weight gain than olanzapine and quetiapine; and (2) less prolactin increase than olanzapine, quetiapine and risperidone. Results from the manufacturers' economic evaluation showed that use of aripiprazole second-line dominated all of the other treatment strategies that were considered. However, there was considerable uncertainty in this result, and clinical advisors indicated that the actual treatment strategy employed in practice is likely to be dependent upon the patient's characteristics. The ERG demonstrated that if this personalised medicine resulted in improved cost effectiveness for any of the other treatment strategies, then they had the potential to dominate use of aripiprazole second-line. In conclusion, whilst a strategy including aripiprazole appeared to be cost effective relative to a strategy without it, there was not robust enough evidence to recommend a specific place for aripiprazole within the treatment pathway.

Cost-effectiveness of Medicare drug plans in schizophrenia and bipolar disorder

BACKGROUND

Medicare Part D has a drug coverage gap, which imposes risks for discontinuing medications, particularly in mental health disorders where drug costs are high. However, some beneficiaries have generic drug coverage in the gap.

OBJECTIVES

To examine the health outcomes and cost-effectiveness of generic-drug coverage compared with no gap coverage in patients with bipolar disorder and schizophrenia.

STUDY DESIGN

Markov model-based cost-effectiveness analysis using identical hypothetical cohorts to examine drug coverage strategies.

METHODS

The incremental cost-effectiveness of Part D coverage strategies was estimated, using differences in medical costs and quality-adjusted life years between plans. Coverage strategy-specific costs and hospitalization rates were obtained from 2007 Medicare data, adjusted for age, sex, race, and health status.

RESULTS

When comparing generic-only coverage with no gap coverage, generic-only coverage cost less and was more effective than no gap coverage, due mainly to lower hospitalization rates. In sensitivity analyses, generic-only coverage continued to be favored over no gap coverage unless generic coverage costs increased > 3% in bipolar disorder and > 5% in schizophrenia; generic coverage in the gap was also favored in probabilistic sensitivity analyses.

CONCLUSIONS

In Medicare Part D, generic drug coverage was cost saving compared with no coverage in bipolar disorder and schizophrenia while improving health outcomes. Policy makers and insurers might consider generic-only coverage, rather than no gap coverage, to both conserve healthcare resources and improve health.

Medical costs and vasculometabolic comorbidities among patients with bipolar disorder in Taiwan - a population-based and matched-control study

BACKGROUND

Bipolar disorder (BD) is a costly disease with a high rate of vasculometabolic comorbidities. The aims of this study were to explore the 1-year treatment cost, including total medical and non-psychiatric services, and the prevalence of vasculometabolic comorbidities in individuals with BD.

METHODS

A nationwide population-based dataset, covering the years 2006 and 2007, was obtained from the Taiwan National Health Insurance claims database. The study sample comprised patients discharged from hospitals between 1 January 2006 and 31 December 2007. Annual non-psychiatric and total medical costs and vasculometabolic comorbidities were examined. Generalized linear models were used to examine the medical costs, and conditional logistic regression analyses were carried out to test the prevalence of vasculometabolic comorbidities in people with BD and to compare this with that found in matched controls.

RESULTS

The total medical cost was 11-fold higher (New Taiwan [NT] $227,040 vs. NT$20,461), and the non-psychiatric medical cost was 1.7-fold higher (NT$33,173 vs. NT$19,406) with regard to the individuals with BD vs. the matched controls. The prevalence of vasculometabolic comorbidities was significantly higher in the individuals with BD than in the controls (ratio ranging from 1.86 to 4.06).

CONCLUSIONS

Both the non-psychiatric healthcare utilization and the prevalence of vasculometabolic comorbidities are higher with regard to individuals with BD vs. their matched controls. Therefore, treatment of BD should integrate medical and psychiatric care to decrease the impact of medical comorbidities, which may also decrease the overall medical cost.

Quetiapine: a pharmacoeconomic review of its use in bipolar disorder

This article briefly summarizes the burden of bipolar disorder and the clinical profile of quetiapine (Seroquel®) in the management of bipolar disorder, followed by a detailed review of pharmacoeconomic analyses. Quetiapine is an atypical antipsychotic that is available in numerous countries as immediate-release and extended-release tablets for the treatment of major psychiatric disorders, including bipolar disorder. Randomized, double-blind, placebo-controlled trials with quetiapine have demonstrated its efficacy in bipolar I and II disorders, and the drug has been generally well tolerated in clinical trials. Three cost-effectiveness analyses of maintenance therapy in bipolar I disorder, which used similar Markov models and incorporated data from key clinical trials and a number of other sources, showed that quetiapine, as adjunctive therapy with mood stabilizers (lithium or divalproex), was a cost-effective treatment option from the healthcare payer perspective in the UK and the US. Quetiapine either dominated comparators (typically mood stabilizers alone) or was associated with incremental cost-effectiveness ratios that were usually well below widely accepted thresholds of cost effectiveness. One of the studies evaluated extended-release quetiapine, although clinical efficacy data used in the Markov model were for the immediate-release formulation. In another analysis, which used a discrete-event simulation model and was conducted from the perspective of the UK healthcare payer, quetiapine monotherapy was cost effective compared with olanzapine monotherapy as maintenance treatment for all phases of bipolar I or II disorder. In this model, favourable results were also shown for quetiapine (with or without mood stabilizers) compared with a wide range of maintenance therapy regimens. Another modelled analysis conducted from the UK healthcare payer perspective showed that quetiapine was dominated by haloperidol in the short-term treatment of a manic episode in patients with bipolar I disorder. Both favourable and unfavourable results have been reported in cost analyses of quetiapine in bipolar disorder (type I or type not specified). Possible explanations for some of the variability in results of the pharmacoeconomic analyses include heterogeneity among the models in terms of input parameters or assumptions in the base-case analyses, country- or region-specific differences in estimates of healthcare resource use and associated costs, variability in treatment alternatives, and differences in the year of costing and discounting used in the analyses. In addition, some of the studies had short time horizons and focused on acute manic episodes only, whereas others were longer-term analyses that considered the full spectrum of health states in patients with bipolar disorder. Various limitations of the studies have been recognized, and results from one country may not be applicable to other countries. In conclusion, results of available pharmacoeconomic analyses provide evidence of the cost effectiveness of quetiapine as an adjunct to mood stabilizers for maintenance therapy in (primarily type I) bipolar disorder from a healthcare payer perspective in the UK and the US. Some evidence is available to support the cost effectiveness of quetiapine monotherapy or the use of extended-release quetiapine as adjunctive therapy with mood stabilizers in this setting, although further analyses appear to be warranted. Whether these findings apply to other geographical regions requires further study. Evidence for the long-term (>2-year) cost effectiveness of quetiapine in bipolar disorder is currently limited and further studies are also needed to address the cost effectiveness of quetiapine from a societal perspective and in bipolar II disorder.

Cost effectiveness of quetiapine in patients with acute bipolar depression and in maintenance treatment after an acute depressive episode

BACKGROUND

Bipolar disorder has a significant impact upon a patient's quality of life, imposing a considerable economic burden on the individual, family members and society as a whole. Several medications are indicated for the acute treatment of mania and depression associated with bipolar disorder as well as for maintenance therapy; however, these have varying efficacy, tolerability and costs.

OBJECTIVE

The objective of this study was to develop a new discrete-event simulation model to analyse the long-term consequences of pharmacological therapy for the management of bipolar I and II disorders (acute treatment of episodes of mania and depression as well as maintenance therapy).

METHODS

Probabilities of remission and relapse were obtained from clinical trial data and meta-analyses. Costs (year 2011 values) were assessed from a UK healthcare payer's perspective, and included pharmacological therapy and resource use associated with the treatment of mood events and selected adverse events. The health effects were measured in terms of QALYs.

RESULTS

For a patient starting with acute depression or in remission at 40 years of age (which was the average age in the clinical trials), quetiapine 300 mg/day was a cost-effective strategy compared with olanzapine 15 mg/day over a 5-year time frame. With acute bipolar depression as a starting episode, the 5-year medical costs were £323 higher and QALYs were 0.038 higher for quetiapine compared with olanzapine, corresponding to a cost-effectiveness ratio of £8600 per QALY gained.

CONCLUSION

Compared with olanzapine, the results suggest that quetiapine is cost effective as a maintenance treatment for bipolar depression.

Prevalence of metabolic syndrome in bipolar disorder: an exploratory study from North India

PURPOSE

To study the prevalence of metabolic syndrome in patients with bipolar disorder.

MATERIAL AND METHOD

By using purposive random sampling 200 patients with bipolar disorder receiving treatment were evaluated for presence of metabolic syndrome using International Diabetes Federation (IDF) and modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) criteria.

RESULTS

Eighty patients fulfilled IDF criteria and 82 patients met NCEP ATP-III criteria for metabolic syndrome. There was significant concordance between these two criteria sets for metabolic syndrome (Kappa value 0.979, p<0.015). Among the individual parameters studied--increased waist circumference (70.1%) was the most common abnormality, followed by increased blood pressure (44.5%) and increased triglycerides levels (42%). Compared to patients without metabolic syndrome, patients with metabolic syndrome had significantly higher body mass index and higher percentage of them (74.4% vs 51.7%) were more than 35 years of age. Logistic regression analysis revealed that these two variables significantly predicted metabolic syndrome.

CONCLUSION

Findings of the present study suggest that abdominal obesity is the most common abnormality and metabolic syndrome is best predicted in patients with bipolar disorder by higher age and higher body mass index.

National estimates of the inpatient burden of pediatric bipolar disorder in the United States

BACKGROUND

Pediatric bipolar disorder (BPD) is a debilitating recurrent chronic mental illness, characterized by cycling states of depression, mania, hypomania, and mixed episodes. Similarly to adults, children and adolescents with BPD are typically treated with pharmacotherapy and adjunctive psychotherapy. Nevertheless, emergency-room visits and hospitalizations are common for those suffering from pediatric BPD. Previous studies have shown declining trends in mean inpatient costs and length of stay (LOS) in the hospital for children with BPD.

AIMS

The objectives of this study were to calculate national estimates of the annual burden of inpatient hospitalizations of children and adolescents with BPD in the United States; to describe and compare the mean burden across various patient characteristics, hospital characteristics, and key comorbidities associated with BPD; and to determine the independent effects of these factors on hospitalization costs.

METHODS

Hospitalizations for children and adolescents whose primary diagnosis was BPD were selected from the Kids' Inpatient Database (KID) in 2003 and 2006. The burden for each year was estimated as total number of days in the hospital and total costs. Mean costs were calculated overall and for subpopulations identified by patient and hospital characteristics and by the top six comorbidities found for BPD. Ordinary-least-squares regression models explaining cost were estimated for both 2003 and 2006, and the models were compared by way of a Chow statistical test.

RESULTS

There were 39,136 (40,679) BPD in hospitalizations in 2003 (2006), with total associated costs of USD 176 (USD 233) million in 2003 (2006). The mean cost was USD 4,490 (USD 5,725), while the mean LOS was 8.12 (8.99) days in 2003 (2006). Factors associated with higher cost included youth (younger than 13), being black, being from a high-income family, having many diagnoses, being insured by Medicaid, living in the North East or West regions of the country, and having a long hospital stay. Post-traumatic stress disorder and oppositional defiant disorder were associated with higher costs in 2006.

DISCUSSION

Declining trends in mean cost and LOS, documented in previous studies for children with BPD, persisted into 2003 but showed a slight reversal by 2006. Over the three years, mean LOS rose by a little less than one day, while mean cost (not adjusted for inflation) rose by USD 1,235. Children and adolescents insured through Medicaid tended to stay in the hospital longer and have higher costs than those children who were privately insured.

IMPLICATIONS FOR HEALTH POLICIES

Due to relatively few expensive inpatient procedures for BPD patients, pediatric BPD hospitalizations, relative to hospitalizations overall, were significantly more burdensome on average in terms of days spent in the hospital than in terms of cost. To the extent that early detection of the disease along with appropriate outpatient treatment can be achieved, there could be significant reductions in the risk of hospitalizations for children with BPD.

IMPLICATIONS FOR FURTHER RESEARCH

Further studies should be conducted to determine if average LOS and mean hospitalization cost remain consistent with declining trends or whether the increase between 2003 and 2006 represents a trend reversal.

Comparison of second-generation antipsychotic treatment on psychiatric hospitalization in Medicaid beneficiaries with bipolar disorder

OBJECTIVE

To compare second-generation antipsychotics on time to and cost of psychiatric hospitalization in Medicaid beneficiaries with bipolar disorder.

METHODS

Retrospective study using healthcare claims from 10 US state Medicaid programs. Included beneficiaries were aged 18-64, initiated a single second-generation antipsychotic (aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone) between 1/1/2003-6/30/2008 (initiation date=index), and had a medical claim with an ICD-9-CM diagnosis code for bipolar disorder. A 360-day post-index period was used to measure time to and costs of psychiatric hospitalization (inpatient claims with a diagnosis code for a mental disorder [ICD-9-CM 290.xx-319.xx] in any position). Cox proportional hazards models and Generalized Linear Models compared time to and costs of psychiatric hospitalization, respectively, in beneficiaries initiating aripiprazole vs each other second-generation antipsychotic, adjusting for beneficiaries' baseline characteristics.

RESULTS

Included beneficiary characteristics: mean age 36 years, 77% female, 80% Caucasian, aripiprazole (n=2553), mean time to psychiatric hospitalization or censoring=85 days; olanzapine (n=4702), 81 days; quetiapine (n=9327), 97 days; risperidone (n=4377), 85 days; ziprasidone (n=1520), 82 days. After adjusting for baseline characteristics, time to psychiatric hospitalization in beneficiaries initiating aripiprazole was longer compared to olanzapine (hazard ratio [HR]=1.52, p<0.001), quetiapine (HR=1.40, p<0.001), ziprasidone (HR=1.33, p=0.032), and risperidone, although the latter difference did not reach significance (HR=1.18, p=0.13). The adjusted costs of psychiatric hospitalization in beneficiaries initiating aripiprazole were significantly lower compared to those initiating quetiapine (incremental per-patient per-month difference=$42, 95% CI=$16-66, p<0.05), but not significantly lower for the other comparisons.

LIMITATIONS

This study was based on a non-probability convenience sample of the Medicaid population. Analyses of administrative claims data are subject to coding and classification error.

CONCLUSIONS

Medicaid beneficiaries with bipolar disorder initiating aripiprazole had significantly longer time to psychiatric hospitalization than those initiating olanzapine, quetiapine, or ziprasidone, and significantly lower adjusted costs for psychiatric hospitalization than those initiating quetiapine.

Predictors of medication nonadherence and hospitalization in Medicaid patients with bipolar I disorder given long-acting or oral antipsychotics

PURPOSE

To assess rates and predictors of medication nonadherence and hospitalization among patients with bipolar I disorder.

METHODS

This was a retrospective cohort analysis of Medicaid patients who were aged ≥ 18 years, had ≥ 1 inpatient or ≥ 2 outpatient medical claims indicating bipolar I disorder (ICD-9-CM codes 296.0x-296.1x, 296.4x-296.7x), and filled ≥ 1 prescription for antipsychotic medication between January 1, 2004, and December 31, 2006. Patients were followed for 1 year from the date of first (index) antipsychotic prescription. Patients were required to be continuously eligible for Medicaid without dual Medicare eligibility from 1 year before (baseline) through 1 year after (follow-up) index, and were required to receive ≥ 1 additional antipsychotic during follow-up. Descriptive statistics and predictors of medication nonadherence (medication possession ratio <0.8) and hospitalization were generated.

RESULTS

A total of 9410 patients met study eligibility criteria with a mean age of 38 years; 74% were female and 75% were white. Approximately 31% and 57% had baseline diagnoses of substance abuse and other psychiatric conditions, respectively. During follow-up, roughly 60% of patients were nonadherent and 40% of patients were hospitalized for any reason (37% psychiatric-related). Multivariate analysis showed that new antipsychotic starts, younger patients, those with a baseline concomitant substance abuse diagnosis, those taking a baseline antidepressant, and those with a baseline psychiatric hospitalization had significantly higher risk of nonadherence. Baseline psychiatric hospitalization, baseline substance abuse or other psychosis diagnosis, baseline use of an anxiolytic, anticholinergic, or anticonvulsant, and nonadherence to therapy in the follow-up period were significant predictors of increased risk of hospitalization.

LIMITATIONS

This analysis did not attempt to evaluate the complex relationships among treatment type, adherence, hospitalization, and other variables.

CONCLUSIONS

Study results showed that the risk of nonadherence is relatively high and confirmed that nonadherence is associated with a greater risk of hospitalization.

Brainstorm: occupational choice, bipolar illness and creativity

Although economists have analyzed earnings, unemployment, and labor force participation for those with bipolar illness, occupational choice has yet to be explored. Psychological and medical studies often suggest an association between bipolar illness and creative achievement, but they tend to focus on eminent figures, case studies, or small samples. We seek to examine occupational creativity of non-eminent individuals with bipolar disorder. We use Epidemiologic Catchment Area data to estimate a multinomial logit model matched to an index of occupational creativity. Those with bipolar illness appear to be disproportionately concentrated in the most creative occupational category. Nonparametric kernel density estimates reveal that the densities of the occupational creativity variable for the bipolar and non-bipolar individuals significantly differ in the ECA data, and suggest that the probability of engaging in creative activities on the job is higher for bipolar than non-bipolar workers.

Costs associated with attempted suicide among individuals with bipolar disorder

BACKGROUND

Bipolar disorder is a chronic mood disorder associated with a high risk for suicide attempts, which carry personal, societal, and economical consequences. No information is available on the economic costs associated with suicide attempts among patients with bipolar disorder or the change in economic costs from before to following the suicide attempt.

AIMS OF THE STUDY

The primary objective of this study was to estimate the total health care costs and cost components (inpatient, outpatient, emergency services, and medication) incurred by patients diagnosed with bipolar disorder who attempt suicide. Cost data included psychiatric and non-psychiatric costs. A secondary objective was to compare patients with and without attempted suicide on demographic and clinical characteristics.

METHODS

Data for this retrospective study were obtained from the PharMetrics Integrated Outcomes Database (1995-2005). Patients diagnosed with bipolar disorder with (N = 352) and without (N = 15,102) a suicide attempt were identified and compared on demographics and psychiatric and medical comorbidities. T-tests and chi-square tests were used for group comparisons of patient characteristics. Among patients who attempted suicide and were continuously enrolled in the year before and following the suicide attempt (N = 352), Wilcoxon signed-rank tests were used to compare health care costs between the year prior and the year following the first suicide attempt.

RESULTS

The average total health care cost for the year following the suicide attempt (N = 352) was $25,012, which was more than 2 times higher than the $11,476 incurred in the prior 1-year period (p. < 001). The total health care cost in the first month following the suicide attempt accounted for 28.9% of the total annual cost. The cost distribution over time showed a large spike for inpatient and emergency services costs in the month following the attempt with sustained increases in medication and outpatient costs. Patients with suicide attempt (N = 1,147) were significantly more likely than patients without (N = 15,102) to be younger, female, and to have comorbid psychiatric and medical diagnoses, especially depressive and substance use disorders.

DISCUSSION

The substantial economic costs incurred by patients with bipolar disorder who attempt suicide are marked by an increase in costs of crisis services during the first month following the suicide attempt, along with sustained increases in medication and outpatient costs during the year following the suicide attempt. Limitations of the study include reliance on claims data and potential lack of generalizability beyond private payer data.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

Interventions designed to reduce the risk of suicide attempts among patients diagnosed with bipolar disorder may help decrease the related high economic costs, in addition to helping decrease adverse personal and societal consequences.

IMPLICATIONS FOR HEALTH POLICIES

Cost-benefit analyses of treatment methods for bipolar disorder need to include the considerable expenses associated with suicide attempts. Current findings may also be of value for modeling the cost-effectiveness of treatment for bipolar disorder and of interest to payers and other health care decision makers, especially those involved in developing Medicare capitation models for patients with chronic conditions such as bipolar disorder.

IMPLICATIONS FOR FURTHER RESEARCH

Additional research is needed on the cost of attempted suicide in the treatment of patients with bipolar disorder, especially studies that capture societal costs.

Anticipated Benefits of Care (ABC): psychometrics and predictive value in psychiatric disorders

BACKGROUND

Attitudes and expectations about treatment have been associated with symptomatic outcomes, adherence and utilization in patients with psychiatric disorders. No measure of patients' anticipated benefits of treatment on domains of everyday functioning has previously been available.

METHOD

The Anticipated Benefits of Care (ABC) is a new, 10-item questionnaire used to measure patient expectations about the impact of treatment on domains of everyday functioning. The ABC was collected at baseline in adult out-patients with major depressive disorder (MDD) (n=528), bipolar disorder (n=395) and schizophrenia (n=447) in the Texas Medication Algorithm Project (TMAP). Psychometric properties of the ABC were assessed, and the association of ABC scores with treatment response at 3 months was evaluated.

RESULTS

Evaluation of the ABC's internal consistency yielded Cronbach's alpha of 0.90-0.92 for patients across disorders. Factor analysis showed that the ABC was unidimensional for all patients and for patients with each disorder. For patients with MDD, lower anticipated benefits of treatment was associated with less symptom improvement and lower odds of treatment response [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57-0.87, p=0.0011]. There was no association between ABC and symptom improvement or treatment response for patients with bipolar disorder or schizophrenia, possibly because these patients had modest benefits with treatment.

CONCLUSIONS

The ABC is the first self-report that measures patient expectations about the benefits of treatment on everyday functioning, filling an important gap in available assessments of attitudes and expectations about treatment. The ABC is simple, easy to use, and has acceptable psychometric properties for use in research or clinical settings.

Workplace productivity, employment issues, and resource utilization in patients with bipolar I disorder

OBJECTIVE

To collect workplace productivity and healthcare utilization data from subjects with bipolar I disorder and compare the results with those from normative subjects.

METHODS

A cross sectional survey was administered to patients and recruiting physicians. Data collected included employment status, Endicott Workplace Productivity Scale (EWPS) results, healthcare resource utilization, and quality-of-life.

RESULTS

In comparison with normative subjects, bipolar I subjects reported lower levels of work productivity (measured by the EWPS). Bipolar I subjects also reported more frequent outpatient visits and more prescribed pharmaceuticals. Bipolar I subjects were more likely to miss work, have worked reduced hours due to medical or mental health issues, receive disability payments, been involved in a crime, be uninsured or covered by Medicare, or have been fired or laid off. The study groups were age- and gender-matched to reduce the impact of selection bias associated with a non-randomized study design. Other potential limitations affecting the results of the study include recall bias and possibly an impact of different data collection methods (e.g. Internet versus telephone).

CONCLUSIONS

Bipolar I disorder is associated with a negative effect on work productivity and resource utilization and is an appropriate disease management target for employers and healthcare decision makers.

Healthcare costs of atypical antipsychotic use for patients with bipolar disorder in a Medicaid programme

BACKGROUND

A large body of clinical studies have demonstrated the efficacy of atypical antipsychotic use in the treatment of bipolar disorder. Facing increasing budget pressure, third-party payers, such as state Medicaid programmes in the US, are demanding better understanding of the medical costs beyond atypical antipsychotic drug costs alone in treating bipolar disorder.

OBJECTIVE

To examine healthcare costs associated with the atypical antipsychotic treatments for bipolar disorder from a US third-party payer perspective.

METHODS

This was a retrospective cohort study using an intent-to-treat approach. Using the North Carolina Medicaid claims database (August 2000 to January 2005), 3328 patients with bipolar disorder were identified who were continuously eligible for 3 months pre-initiation and 12 months post-initiation of treatment with an atypical antipsychotic (AP2) or mood stabilizer (MS). Patients were classified into three groups based on the treatment types during the first 30 days after treatment initiation: AP2 monotherapy, AP2 + MS combination therapy, and MS monotherapy. Bipolar-related and total health-related costs were examined for the 12-month period. Propensity score matching was employed to balance baseline characteristics among the three comparison groups. Generalized linear models were further employed to estimate the average treatment effect on the cost outcomes.

RESULTS

Compared with MS monotherapy, AP2 monotherapy and AP2 + MS combination therapy incurred higher medication costs during the 12-month treatment period. Patients receiving AP2 monotherapy had significantly lower bipolar-related medical costs (-$US698; p = 0.002) [year 2004 values] than patients receiving MS monotherapy. However, the inclusion of the medication cost produced no statistically significant difference in bipolar-related total cost (p = 0.14). Similar results were observed for all health-related costs. Patients receiving AP2 + MS therapy incurred significantly higher bipolar-related total costs (+$US1659; p < 0.0001) and all health-related total costs (+$US2115; p < 0.0001) than patients receiving MS monotherapy, which was attributable largely to the higher medication cost.

CONCLUSIONS

From a third-party payer perspective, atypical antipsychotic monotherapy generated higher drug costs but lower medical care costs, resulting in equivalent total healthcare costs over a 1-year period.

Characteristics, healthcare utilization and costs of bipolar disorder type I patients with and without frequent psychiatric intervention in a Medicaid population

OBJECTIVE

To compare characteristics, healthcare resource utilization and costs of Medicaid bipolar disorder (BPD) type I (BP-I) patients with and without frequent psychiatric intervention (FPI).

METHODS

Adults with BP-I, ≥ 1 prescription claim for a mood stabilizer/atypical antipsychotic and 24 months' continuous medical/prescription coverage were identified (MarketScan* Medicaid database). Patients with ≥ 2 clinically significant events (CSEs) during a 12-month identification period had FPI. CSEs included emergency department (ED) visits or hospitalizations with a principal diagnosis of BPD, addition of a new medication to the first observed treatment regimen or ≥ 50% increase in BPD medication dose. Demographic and clinical characteristics were evaluated for the identification period, and healthcare utilization and costs for the 12-month follow-up. Multivariate generalized linear modeling and multivariate logistic regression, respectively, were used to evaluate the impact of FPI on all-cause and psychiatric-related costs and risk of psychiatric-related hospitalization and ED visit during follow-up.

RESULTS

Of 5,527 BP-I patients, 53% had FPI. Relative to patients without FPI, those with FPI were younger and more likely to be female, had higher adjusted all-cause (+US$3,232, p < 0.001) and psychiatric-related (+US$2,519, p < 0.001) costs and higher risk of hospitalization (adjusted odds ratio [OR] = 3.681, 95% confidence interval [CI] = 2.85-4.75) and ED visit (OR = 3.094, 95% CI = 2.55-3.76).

LIMITATIONS

Analysis used a convenience sample of Medicaid enrollees in several geographically dispersed states, limiting generalizability. Analyses of administrative claims data depend on accurate diagnoses and data entry.

CONCLUSION

BP-I patients with FPI incurred significantly higher healthcare resource utilization and costs during the follow-up period than those without FPI.

Clinical characteristics and resource utilization of patients with bipolar disorder who have frequent psychiatric interventions

OBJECTIVE

To compare the demographics, clinical characteristics and resource utilization of patients with bipolar disorder who required frequent psychiatric interventions (FPIs) with those needing fewer interventions in the Duke Healthcare System database between 1999 and 2005.

METHODS

This retrospective analysis was conducted using electronic medical records of bipolar patients with FPIs, defined as having ≥4 clinically significant events (CSEs) in any 12-month period while in the Duke University Healthcare System. CSEs were composed of emergency room visits, inpatient hospitalizations, or a change in psychotropic medication due to psychiatric symptoms (score≥4 on the Clinical Global Impressions-Severity scale). Data were compared between patients with and without FPIs.

RESULTS

Of 632 patients with bipolar disorder 52.5% were identified as having FPIs. These patients were younger and more often female and African American than those with fewer interventions (p<0.01 for all). Patients with FPIs were generally prescribed more psychotropic and non-psychotropic medications, utilized more healthcare resources and experienced more psychiatric co-morbidities than those who did not require FPIs (p<0.01 for all).

LIMITATIONS

These results are from a single healthcare system and may not be generalizable to all patients with bipolar disorder. This analysis was retrospective and relied on availability of adequate information recording and coding of diagnoses by physicians.

CONCLUSIONS

Patients with bipolar disorder who required FPIs were significantly different from those with fewer clinically defined interventions with respect to their demographic and clinical characteristics and prescribed medications.

The cost of relapse for patients with a manic/mixed episode of bipolar disorder in the EMBLEM study

BACKGROUND

Bipolar disorder (BD) is characterized by episodes of mania and depression. The debilitating symptoms during an acute episode require intensive treatment, frequently leading to inpatient psychiatric care, which places significant demands on health and social care systems and incurs substantial costs. However, no study to date has estimated the economic impact of relapse.

OBJECTIVES

To estimate the direct costs associated with relapse in the treatment of BD following an acute manic or mixed episode over a 21-month follow-up period in routine clinical practice in Europe, using data from a large, prospective, observational study.

METHODS

EMBLEM was a prospective, observational study on the outcomes of patients with a manic/mixed episode of BD conducted in 14 European countries. Patients eligible for analysis were those enrolled in the 21-month maintenance phase of the study, following the 3-month acute phase. Relapse was defined as achieving any one of the following criteria: (i) at least a one-point increase in Clinical Global Impression - Bipolar Disorder (CGI-BP) overall score from the previous visit, with a final rating of > or =4; (ii) inpatient admission for an acute episode of BD; or (iii) psychiatrists' confirmation of relapse. Data on healthcare resource use were recorded retrospectively for the four respective periods (3-6, 6-12, 12-18 and 18-24 month visits). Multivariate analyses were performed to compare the cost of resource use (inpatient stay, day care, psychiatrist visits and medication) for those who relapsed during the 21-month maintenance phase and those who never relapsed. A sensitivity analysis was also conducted to examine the 6-month costs during relapse. The analyses were adjusted for patient characteristics and took account of non-Normality of the cost data by using a log link function. UK unit costs were applied to resource use. The analysis was repeated after multiple imputation for missing data. All costs were presented as year 2007/08 values.

RESULTS

A total of 1379 patients completed all visits during the maintenance phase and were eligible for inclusion in the present analysis. Of these, over half (54.3%) experienced relapse during this period. A total of 792 patients without any missing data were eventually included in the final cost model. Costs incurred by patients who relapsed during the 21-month maintenance phase were approximately double those incurred by patients who never relapsed (pounds sterling 9140 vs pounds sterling 4457; p < 0.05). Of the cost difference, 80.3% was accounted for by inpatient stay. Estimates on the economic impact were higher (pounds sterling 11,781 vs pounds sterling 4789; p < 0.05) in the additional analysis with imputed missing data. The impact of relapse was even greater in the 6-month cost comparison. The average 6-month costs for patients who relapsed were found to be about three times higher than for those who did not relapse (pounds sterling 4083 vs pounds sterling 1298; p < 0.05).

CONCLUSIONS

Our findings confirm the significant economic impact of relapse in BD patients after an acute manic or mixed episode, even when considering direct costs only. Such costs were dominated by inpatient stay. Nevertheless, the use of UK unit costs requires caution when interpreting this costing in the context of a specific country, as resource use and the associated costs will differ by country.

Cost effectiveness of adjunctive quetiapine fumarate extended-release tablets with mood stabilizers in the maintenance treatment of bipolar I disorder

BACKGROUND

Bipolar I disorder (BPD I) is a recurrent illness that affects 1% of the US population and constitutes a large economic burden. However, few studies have investigated the cost effectiveness of maintenance treatment options for BPD I.

OBJECTIVE

To determine the cost effectiveness of maintenance treatment with quetiapine fumarate extended-release (XR) tablets in combination with mood stabilizers (lithium or divalproex) in comparison with the following treatments: placebo in combination with lithium or divalproex; no maintenance treatment; lithium monotherapy; lamotrigine monotherapy; olanzapine monotherapy; and aripiprazole monotherapy.

METHODS

The analysis was conducted from the societal and payer perspectives in the US, using a Markov model. The model simulated a cohort of 1000 stabilized BPD I patients and estimated the quarterly risk in three health states: euthymia, mania and depression. Efficacy data were derived from two randomized, double-blind trials comparing quetiapine + lithium/divalproex with placebo + lithium/divalproex for up to 2 years, as well as other published literature. Resource data were extracted from published literature. Drug costs, hospitalizations and physician visits were among the direct costs. Indirect costs included absenteeism, and mortality rates included suicide. Benefits and costs were discounted at 3% and the price reference year was 2009. Endpoints included number of acute mood episodes, hospitalizations due to an acute mood event and costs per QALY. Probabilistic sensitivity analysis (PSA) was conducted to evaluate uncertainty in the model inputs.

RESULTS

Treatment with quetiapine XR + lithium/divalproex was associated with reductions in acute mania (46%), acute depression (41%) and related hospitalizations (44%) compared with placebo + lithium/divalproex, and similar reductions in events were observed relative to lithium monotherapy. In the base-case analysis from the payer perspective, the discounted incremental cost per QALY for quetiapine XR + lithium/divalproex compared with placebo + lithium/divalproex was $US22 959, and compared with lithium monotherapy was $US100 235, while all other comparators were dominated. PSA showed these results to be robust to select assumptions.

CONCLUSIONS

Quetiapine XR + lithium/divalproex may be a cost-effective maintenance treatment option for patients with BPD I.

[Direct health-related costs of severely mentally ill patients and their informal carers in community care]

OBJECTIVE

Within the last few years, a small number of German cost analyses of patients treated in community mental health care settings was presented. None of these studies, however, examined direct health care costs of the patients' close reference persons focusing on costs associated with providing informal care. Therefore, our study aimed to analyse health-related direct costs of severely ill patients suffering from affective or schizophrenic disorders, and of their informal carers during community mental health care; further, we examined if these costs differed between the diagnostic groups.

METHODS

69 patients currently treated by community mental health services of the Dresden region and their closest reference person providing informal care were assessed twice within an interval of 3 months by use of the CSSRI- D. Thus, direct health care costs of patients and their informal carers covering a 6-months-period could be calculated.

RESULTS

25.35% and 38.24%, respectively, of the closest reference persons' direct health care costs were caused by the situation of acting as informal carer. This was 9.12% and 22.74%, respectively, of the patients' direct health care costs assessed at the same time-points. Patients' costs did not differ between the diagnostic categories, but were influenced by the current severity of psychopathological symptoms. Reference persons' costs were influenced by the severity of the patient's psychopathological symptoms, but also by the social control behaviour of the reference persons themselves as well as by their sense of coherence.

CONCLUSIONS

While a replication of our findings is urgently needed, they point at the economic significance of direct health-related costs caused by acting as informal carers. Further, therapeutic approaches adequate for minimizing these costs could be suggested, like emphasizing protective factors of mental well-being in psycho-educational programmes for relatives.

Cost analysis in a Medicaid program for patients with bipolar disorder who initiated atypical antipsychotic monotherapy

BACKGROUND

Use of atypical antipsychotics in treatment of patients with bipolar disorder is increasingly common, yet few studies have systematically investigated or compared medical costs associated with use of specific atypical antipsychotics.

OBJECTIVE

To evaluate the direct healthcare costs associated with olanzapine, risperidone, or quetiapine monotherapy among Medicaid patients diagnosed with bipolar disorder (ICD-9: 296.4x-296.8x).

METHODS

North Carolina Medicaid patients with bipolar disorder were followed for 12 months after initiation of atypical antipsychotic monotherapy (index date). They had no bipolar-related medical visit, hospitalization, or use of atypical antipsychotics 90-days prior to the treatment initiation. Costs of index drug, all bipolar-related medical care, and all health-related costs were examined. A two-stage sample selection model was employed to account for potential confounders and sample selection bias. Medication adherence measures using cumulative medication acquisition and cumulative medication gap were calculated as separate outcomes.

RESULTS

Inclusion criteria were met by 838 continuously eligible patients (393 olanzapine, 262 risperidone, 183 quetiapine). Drug-taking adherence was similar across the drug cohorts. After adjusting for potential confounders, patients taking olanzapine incurred $863 (p < 0.001) and $449 higher (p < 0.01) index drug costs than patients taking risperidone and quetiapine, respectively. Bipolar-related medical costs for patients taking olanzapine were higher ($616; p = 0.06) than for patients taking risperidone at 10% significance level, while such costs for patients taking olanzapine and quetiapine were similar. Total health-related costs did not differ across patient cohorts, including or excluding the index drug costs.

LIMITATIONS

The final study sample is a highly selected one based on the study design. This sample may not represent the entire bipolar population. The criteria used to guard against omitting bipolar disorder patients misdiagnosed with major depression need further validation.

CONCLUSIONS

No evidence was identified that there is any difference for total health-related costs in using olanzapine, risperidone, or quetiapine monotherapy to treat bipolar disorder, from a Medicaid payer's perspective. The clinical difference between these atypical antipsychotic drugs for the treatment of bipolar disorder could be of more interest than the economic difference.

Cost-effectiveness of quetiapine with lithium or divalproex for maintenance treatment of bipolar I disorder

BACKGROUND

Bipolar I disorder is a recurrent illness that affects 1% of the US population and constitutes a large economic burden. Few studies have investigated the cost-effectiveness of maintenance treatment options. The objective of this analysis was to assess the cost-effectiveness of quetiapine (QTP) in combination with lithium (Li) or divalproex (DVP) compared with that of Li or DVP alone for maintenance treatment of bipolar disorder.

METHODS

The cost-effectiveness of maintenance treatment with QTP in combination with Li or DVP was compared with placebo (PBO) in combination with Li or DVP from a US direct costs perspective using a Markov model. The model simulated a cohort of 1,000 stabilized patients with bipolar I disorder and estimated the quarterly risk in three health states: euthymia, mania, and depression. Efficacy data were derived from two randomized, double-blind, placebo-controlled trials comparing QTP + Li/DVP with PBO + Li/DVP for up to 2 years. Resource data were obtained from published literature. Direct costs included drug costs, hospitalizations, and physician visits. Outcomes and costs were discounted at 3% and the price reference year was 2007. Endpoints included the number of acute mood episodes, hospitalizations due to an acute mood event, and costs per quality-adjusted life-years. A probabilistic sensitivity analysis (PSA) was conducted to evaluate uncertainty.

RESULTS

In the base-case analysis, QTP + Li/DVP dominated PBO + Li/DVP. The PSA showed these results to be robust. In addition, treatment with QTP + Li/DVP was associated with reductions in acute manic episodes (46%), acute depressive episodes (41%), and related hospitalizations (44%) compared with PBO + Li/DVP.

CONCLUSIONS

These analyses, based on two randomized clinical trials, suggest that QTP + Li/DVP is a cost-effective maintenance treatment option for patients with bipolar I disorder compared with Li or DVP alone.

Impact of bipolar disorder in employed populations

OBJECTIVE

To review literature on the impact of bipolar disorder on the workplace, with respect to costs to employers, workplace productivity and functioning, and any employer-initiated programs implemented with the aim of improving work attendance and performance.

STUDY DESIGN

Systematic literature review.

METHODS

Original studies relating to bipolar disorder in the workplace were identified from PubMed and EMBASE using a reproducible, systematic search strategy in July 2007. There were no constraints on publication dates. Results were first evaluated by title and/or abstract. Full manuscripts of potentially relevant papers then were obtained and assessed for inclusion. Productivity data were extracted in terms of absenteeism, short-term disability, presenteeism, and any associated cost burden to US employers.

RESULTS

Seventeen studies met search criteria and were included in this review. The data indicate that bipolar disorder imposes a significant financial burden on employers, costing more than twice as much as depression per affected employee. A large proportion of the total cost of bipolar disorder is attributable to indirect costs from lost productivity, arising from absenteeism and presenteeism. The presence of comorbid conditions and stigma in the workplace may lead to delays in accurate diagnosis and effective management of bipolar disorder.

CONCLUSION

Bipolar disorder among the working population can have a significant, negative effect on work relationships, attendance, and functioning, which can lead to substantial costs to US employers arising from lost productivity. There is a need for workplace initiatives to address the health and cost consequences of bipolar disorder within an employed population.

Treatment costs and health care utilization for patients with bipolar disorder in a large managed care population

OBJECTIVES

This study measured the treatment cost of bipolar disorder (BPD), decomposed the cost into that portion which was directly BPD-related and that attributable to comorbidities, and compared health-care utilization and costs across groups of patients with different drug regimens.

METHODS

Using a multistate managed-care-organization claims database, a cohort of 67,862 BPD patients were selected and followed for the length of their enrollment between January 1, 1998 and December 31, 2002. All costs associated with the patients' medical claims were adjusted to 2002 dollars using the medical component of Consumer Price Index. Patients were classified into three groups based on their drug regimen: atypical antipsychotics (ATYP), atypical antipsychotics plus mood stabilizers (ATYP + MS), and mood stabilizers only (MS). The Charlson comorbidity index was used to control for comorbid conditions. Using both Poisson and log-linear regression analyses, numbers of hospitalizations, emergency room (ER) visits, and outpatient visits, as well as treatment costs per enrolled month, were regressed on age, sex, medication regimen, and clinical comorbidities.

RESULTS

The mean charge and reimbursement per patient-year were $12,797 and $6581, respectively. Of the treatment cost, 33% was BPD-related, and 67% was attributed to comorbidities. Compared to patients in the MS treatment regimen, higher treatment costs were associated with ATYP (Rate Ratio = 1.24, 95% CI 1.17-1.31) and ATYP + MS (RR = 1.52, 1.47-1.56). Moreover, higher costs were associated with key comorbidities like personality disorder (RR = 1.45, 1.37-1.53). Patients on the ATYP regimen had higher risks of hospitalization (RR = 1.44, 1.33-1.56) and ER visits (RR = 1.15, 1.04-1.27), but lower risk of outpatient visits (RR = 0.81, 0.76-0.86).

CONCLUSIONS

Controlling treatment costs for BPD patients requires focusing on patients with key comorbidities and monitoring the association between treatment regimen and resource use.

A systematic review and economic model of the clinical effectiveness and cost-effectiveness of interventions for preventing relapse in people with bipolar disorder

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of pharmacological and/or psychosocial interventions for the prevention of relapse in people with bipolar disorder.

DATA SOURCES

Major electronic databases were searched up to September 2005.

REVIEW METHODS

Systematic reviews were undertaken on the clinical and economic effectiveness of treatments. An analysis was performed using the methods of mixed treatment comparison (MTC) to enable indirect comparisons to be made between the treatments. An economic model of treatments for the prevention of relapse in bipolar disorder was developed.

RESULTS

Forty-five trials were included in the clinical effectiveness review; all but one studied adults. This review found that for the prevention of all relapses, lithium, valproate, lamotrigine and olanzapine performed better than placebo, with lithium and lamotrigine having the strongest evidence. For depressive relapse prevention, valproate, lamotrigine and imipramine performed better than placebo, with evidence strongest for lamotrigine and weakest for imipramine. For manic relapses, lithium and olanzapine performed significantly better than placebo. The MTC found that the best treatment for bipolar I patients with mainly depressive symptoms was valproate, followed by lithium plus imipramine. For bipolar I patients with mainly manic symptoms, olanzapine was the best treatment. From the studies investigating psychosocial interventions, there were few data for each comparison and outcome. The evidence suggests that cognitive behaviour therapy (CBT), in combination with usual treatment, is effective for the prevention of relapse. Group psychoeducation and possibly family therapy may also have roles as adjunctive therapy for preventing relapse. The results from the decision analytic model developed on the cost-effectiveness of long-term maintenance treatments of bipolar I patients suggest that the choice of treatment is dependent upon a number of factors: the previous episode history of a patient and the mortality benefit assumed for lithium strategies. The results from the base-case analysis for patients with a recent history of depression suggest that valproate, lithium and the combination of lithium and imipramine are potentially cost-effective depending upon the amount that a decision-maker is willing to pay for additional health gain. Using conventional amounts that the NHS is prepared to pay for health gain, then the lithium-based strategies appear to be potentially cost-effective for this group. For patients with a recent history of mania, the choice of pharmacological intervention appears to be between olanzapine and lithium monotherapy. Again using conventional threshold as a reference point, the results suggest that lithium is the most cost-effective therapy. Excluding the additional mortality benefit associated with lithium-based strategies resulted in all treatments for patients with a recent history of a depressive episode being dominated by valproate and, in the case of patients with a recent history of a manic episode, by olanzapine.

CONCLUSIONS

Lithium, valproate, lamotrigine and olanzapine are effective as maintenance therapy for the prevention of relapse in bipolar disorder. Olanzapine and lithium are efficacious for the prevention of manic relapses and valproate, lamotrigine and imipramine for the prevention of depressive relapse. There is some evidence that CBT, group psychoeducation and family therapy might be beneficial as adjuncts to pharmacological maintenance treatments. Insufficient information is available regarding the relative tolerability of the treatments or their relative effects on suicide rate and mortality. For patients with a recent depressive episode, valproate, lithium monotherapy and the combination of lithium and imipramine are potentially cost-effective. For patients with a recent manic episode, olanzapine and lithium monotherapy are potentially cost-effective. The cost-effectiveness estimates in both groups of patients were shown to be sensitive to the assumption of a reduced suicidal risk associated with lithium-based strategies. Further research is needed into the adverse effects of all treatments and the differential effects of agents. Good-quality trials of valproate, of combination therapy, e.g. lithium plus a selective serotonin reuptake inhibitor antidepressant, of psychosocial interventions and of the disorder in children are also required.

Influence of medication choice and comorbid diabetes: the cost of bipolar disorder in a privately insured US population

BACKGROUND

Bipolar disorder is the most expensive mental disorder for US employer health plans. No published studies have examined the impact of comorbid diabetes on the cost of treating bipolar disorder. The objectives of this work were to determine the direct costs incurred by patients with bipolar disorder in a US managed care plan, and to examine the influence (1) of drug therapy regimen on bipolar-related costs, and (2) of diabetes on bipolar-related and all-cause costs.

METHODS

A retrospective analysis of claims in a US private insurance database from January 1, 1999 through December 31, 2002 was performed. The database included at least 4.7 million enrollees each year. Diagnosis codes were used to identify patients with bipolar disorder; patients with diabetes were identified using diagnosis codes and medication use.

RESULTS

From 1999-2002, treated bipolar disorder was identified in 262 (33.9) [mean (standard deviation)] cases per 100,000 enrollees. Among patients with bipolar disorder in this cohort, between 6.3 and 7.4% were treated for diabetes each year. Among patients with newly treated bipolar disorder, 61.8% received initial therapy with only mood stabilizers, 24.3% received only atypical antipsychotics, and 13.9% received both. Mean all-cause cost for patients with bipolar disorder was US$2,690 in the 6 months before the first bipolar-related claim, and US$6,826 in the following year. Of the latter cost, bipolar-related cost was US$1,272. Patients with comorbid diabetes had much higher all-cause cost (US$11,317) than those without diabetes in the year following the first bipolar-related claim, but only slightly higher bipolar-related cost (US$1,349). Among newly treated bipolar disorder patients, all-cause and bipolar-related cost in the year after diagnosis was lowest in patients receiving only mood stabilizers. Ordinary least squares regression analysis found that treatment with mood stabilizers only was associated with 41% lower bipolar-related cost than treatment with atypical antipsychotics only (P < .001). Significant individual associations were also found between bipolar-related cost and bipolar disorder I diagnosis, severe bipolar disorder and comorbid personality disorders (P < .001 for each) but not comorbid diabetes (P = .27).

CONCLUSIONS

These results suggest that patients with bipolar disorder who receive only mood stabilizer therapy incur lower bipolar-related and all-cause cost than those receiving only atypical antipsychotics. In contrast to that for all-cause cost, comorbid diabetes had little impact on direct costs related to treating bipolar disorder itself.

Treatment costs related to bipolar disorder and comorbid conditions among Medicaid patients with bipolar disorder

OBJECTIVE

This study assessed costs among patients with bipolar disorder for treatment related to bipolar disorder and to comorbid conditions. Risk factors associated with costs were also assessed.

METHODS

Data (January 1998 to December 2002) were from a seven-state Medicaid managed care claims database for 13,471 patients who had received a diagnosis of bipolar disorder, most of whom received medications. Each medical claims cost was adjusted by the medical component of the Consumer Price Index as the dollar value in 2002. In a Poisson regression analysis, treatment costs per enrollment month were regressed on patient's age, gender, medications, and clinical comorbidities.

RESULTS

Bipolar disorder treatment accounted for 30% of costs and comorbid disorders for 70%. Key cost components were inpatient care (35%), outpatient care (16%), prescriptions (13%), and physician encounters (11%). Patients with bipolar disorder received a variety of medications: lithium, 13%; anticonvulsants, 35%; second-generation antipsychotics, 24%; first-generation antipsychotics, 22%; and antidepressants, 42%. Compared with the costs for patients receiving antidepressants alone or no medication, the high costs for bipolar disorder treatment and overall treatment were associated with use of second-generation antipsychotics (rate ratio [RR]=1.71, 95% confidence interval [CI]=1.58-1.86 and RR=1.26, CI=1.18-1.34, respectively) and use of anticonvulsants (RR=1.37, CI=1.26-1.48 and RR=1.06, CI=1.00-1.12). Higher costs were significantly associated with key comorbidities, such as drug abuse (RR=1.58, CI=1.47-1.70), cerebral-vascular disease (RR=1.72, CI=1.51-1.94), ischemic heart disease (RR=1.47, CI=1.30-1.66), and hypertension (RR=1.44, CI=1.33-1.56).

CONCLUSIONS

Cost-containment efforts may need to manage or prevent key comorbidities among patients with bipolar disorder and to evaluate the association between antipsychotic use and treatment outcomes and hospital services.