The economic burden of bipolar I disorder in the United States in 2015

Impact of formulary-related pharmacy claim rejections of cariprazine on health care utilization and treatment patterns among patients with bipolar I disorder

BACKGROUND

Formulary restrictions, intended to limit inappropriate medication use and decrease pharmacy costs, may prevent or delay patients with bipolar I disorder from initiating cariprazine, a dopamine D3-preferring D3/D2 and serotonin 5HT1A receptor partial agonist that is approved to treat manic/mixed or depressive episodes associated with bipolar I disorder. Little is known about the downstream consequences of formulary-related cariprazine prescription rejections.

OBJECTIVE

To evaluate the impact of formulary-related cariprazine claim rejections on health care resource utilization (HCRU) and treatment patterns among patients newly prescribed cariprazine for bipolar I disorder.

METHODS

Symphony Health Integrated Dataverse was used to identify commercially insured adults (aged ≥18 years) with bipolar I disorder and at least 1 pharmacy claim for cariprazine (rejected because of formulary restrictions or approved; date of the first claim is the index date) from March 2015 through October 2020. Formulary-related rejection reasons included noncoverage, prior authorization requirement, and step therapy requirement. Baseline characteristics were evaluated during the 12 months pre-index and balanced between rejected and approved cohorts using 1:2 propensity score matching. HCRU outcomes included all-cause and mental health (MH)-related hospitalizations, emergency department (ED) visits, and outpatient visits. Treatment patterns were analyzed descriptively and included treatment delay and atypical antipsychotic use. HCRU was reported per patient-year and compared between cohorts using rate ratios; 95% CIs and P values were calculated using nonparametric bootstrap procedures.

RESULTS

The matched rejected and approved cohorts comprised 1,554 and 3,108 patients, respectively. The rejected cohort had 22% more all-cause and 24% more MH-related hospitalizations per patient-year vs the approved cohort (rate ratio [95% CI], all-cause: 1.22 [1.01-1.48], P = 0.024; MH-related: 1.24 [1.01-1.55], P = 0.044). ED and outpatient visits were numerically, but not significantly, greater in the rejected cohort. Of patients in the rejected cohort, 34.7% never received an atypical antipsychotic and 76.8% never received cariprazine. For those who later received cariprazine or another atypical antipsychotic, the average treatment delay was approximately 6 months (188 days) and approximately 4 months (123 days) after the initial rejection, respectively.

CONCLUSIONS

Patients with bipolar I disorder and formulary-related cariprazine claim rejections experienced significantly more hospitalizations than patients whose initial claim was approved; ED and outpatient visits were similar between cohorts. Less than a quarter of patients whose initial claim was rejected later received cariprazine, and more than one-third never received any atypical antipsychotic. To our knowledge, this is the first study to evaluate the impact of formulary-related rejections of cariprazine on HCRU and treatment patterns in patients with bipolar I disorder.

Relationship between social determinants of health and hospitalizations and costs among patients with bipolar disorder 1

BACKGROUND

Bipolar disorder type 1 (BD-1) is a serious episodic mental illness whose severity can be impacted by social determinants of health (SDOH). To date the relationship of social and economic factors with health care utilization has not been formally analyzed using real-world data.

OBJECTIVE

To describe patient characteristics and assess the influence of SDOH on hospitalizations and costs in patients with BD-1 insured with commercial and managed Medicaid health plans.

METHODS

This retrospective observational study used data from the Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry to identify patients aged 18 years and older with evidence of BD-1 between July 1, 2016, and December 31, 2018. SDOH were linked to patients at the "near neighborhood" level (based on ZIP9 area). Multivariable models assessed the relationship between patient characteristics and hospitalizations (incidence rate ratios [95% CI]) and costs (cost ratios [95% CI]).

RESULTS

Of 243,286 patients with BD-1, 62,148 were covered by commercial insurance and 181,138 by Medicaid. Mean ages [±SD] were similar (commercial 39.8 [±14.8]; Medicaid 40.1 [±13.6]), with more female patients in both cohorts (commercial 59.8%; Medicaid 65.4%). All-cause hospitalization rates were 21.6% for commercial and 35.1% for Medicaid patients; emergency department visits were 39.7% and 64.3%, respectively. All-cause costs were $15,379 [±$27,929] for commercial and $21,474 [±$37,600] for Medicaid. Older age was a significant predictor of fewer hospitalizations compared with those aged younger than 30 years, particularly ages 40-49 for both commercial (0.60 [0.57-0.64]) and Medicaid (0.82 [0.80-0.85]). Increasing age was associated with significantly higher costs, especially age 65 and older (commercial 1.37 [1.31-1.44]); (Medicaid 1.43 [1.38-1.49]). Initial treatment with antipsychotics plus antianxiety medications was a significant predictor of higher hospitalizations (commercial 2.12 [1.98-2.27]; Medicaid 1.62 [1.57-1.68]) and higher costs (commercial 1.86 [1.80-1.92]); Medicaid 1.80 [1.76-1.84]). Household income was inversely associated with hospitalizations for Medicaid (<$30,000 [1.16 (1.12-1.19)]; $30,000-$39,999 [1.11 (1.07-1.15)]; $40,000-$49,999 [1.08 (1.05-1.12)]; $50,000-$74,999 [1.06 (1.02-1.09)]). Not speaking English well or at all was associated with 90% higher hospitalizations for commercial patients (1.93 [1.36-2.76]) but 40% fewer hospitalizations for Medicaid patients (0.59 [0.53-0.67]). Low English language proficiency was associated with significantly higher costs for commercial patients (2.22 [1.86-2.64]) but lower costs for Medicaid patients (0.57 [0.53-0.61]).

CONCLUSIONS

Medicaid patients with BD-1 had high SDOH burden, hospitalizations, and costs. The association of lower English proficiency with fewer hospitalizations and lower costs in Medicaid patients suggests a potential disparity in access to care. These findings highlight the importance of addressing social risk factors to advance health equity in treatment of mental illness.

Functional Alterations in Patients with Bipolar Disorder and Their Unaffected First-Degree Relatives: Insight from Genetic, Epidemiological, and Neuroimaging Data

Bipolar disorder (BD) profoundly affects cognitive and psychosocial functioning, leading to a significant illness burden on patients and their families. Genetic factors are predominant in the onset of bipolar disorder and functional impairments. This disorder exhibits a strong family aggregation, with heritability estimates reaching up to 80%. Individuals with BD often experience impaired functioning, especially in significant areas such as physical performance, sleep, cognition, interpersonal interactions, socioeconomic status, family and marital relationships, work and school performance, well-being, and life expectancy. However, patients with different subtypes exhibit significant heterogeneity in social functioning, cognition, and creativity levels. There are notable differences in psychosocial and cognitive function in their unaffected first-degree relatives (UFR) who do not suffer but may carry susceptibility genes compared to healthy control (HC) without a family history. The observations indicate common genetic structures between BD patients and their UFR, which results in varying degrees of functional abnormalities. Therefore, this article mainly provides evidence on cognition, creativity, and psychosocial functioning in patients with BD and their UFR to provide a more comprehensive understanding of this critical topic in the field of BD. By integrating various findings, including clinical data and neuroimaging studies, our article aims to provide insights and valuable information for a deeper exploration of the pathogenesis of BD and the development of more targeted therapeutic strategies in the future.

Emotional urgency predicts bipolar symptoms, severity, and suicide attempt better than non-emotional impulsivity: a cross-sectional study

Introduction

Emotional urgency is an emotion-based subdimension of trait impulsivity that is more clinically relevant to psychopathology and disorders of emotion dysfunction than non-emotional subdimensions (i.e., lack of perseverance, sensation seeking, lack of premeditation). However, few studies have examined the relative effects of emotional urgency in bipolar disorder. This cross-sectional study aimed to establish the clinical relevance of emotional urgency in bipolar disorders by (1) explicating clinically relevant correlates of emotional urgency and (2) comparing its effects against non-emotional impulsivity subdimensions.

Methods and results

A total of 150 individuals with bipolar disorder were recruited between October 2021 and January 2023. Zero-order correlations found that emotional urgency had the greatest effect on bipolar symptoms (r = 0.37 to 0.44). Multiple two-step hierarchical regression models showed that (1) positive urgency predicted past manic symptomology and dysfunction severity (b = 1.94, p < 0.001 and 0.35 p < 0.05, respectively), (2) negative urgency predicted current depression severity, and (3) non-emotional facets of impulsivity had smaller effects on bipolar symptoms and dysfunction by contrast, and were non-significant factors in the final step of all regression models (b < 0.30, ns); Those who had a history of attempted suicide had significantly greater levels of emotional urgency (Cohen's d = -0.63).

Discussion

Notwithstanding the study's limitations, our findings expand status quo knowledge beyond the perennial relationship between non-emotion-based impulsivity and bipolar disorder and its implications.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers

OBJECTIVE

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.

METHODS

The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.

RESULTS

Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.

CONCLUSIONS

Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Beyond clinical outcomes: Case control study of the role of race in disruptive life events for people with serious mental illness

OBJECTIVE

To understand how race and serious mental illness (SMI) interact for disruptive life events defined as financial (bankruptcy and judgement filings), and non-financial (arrests).

METHODS

Patients were adults with schizophrenia (SCZ; N = 16,159) or bipolar I disorder (BPI; N = 30,008) matched 1:1 to patients without SMI (non-SMI) from health systems in Michigan and Southern California during 1/1/2007 through 12/31/2018. The main exposure was self-reported race, and the outcome was disruptive life events aggregated by Transunion. We hypothesized that Black patients with SCZ or BPI would be the most likely to experience a disruptive life event when compared to Black patients without SMI, and all White or Asian patients regardless of mental illness.

RESULTS

Black patients with SCZ had the least likelihood (37% lower) and Asian patients with BPI had the greatest likelihood (2.25 times higher) of experiencing a financial disruptive life event among all patients in the study. There was no interaction of race with either SCZ or BPI for experiencing an arrest. The findings did not support our hypotheses for patients with SCZ and partially supported them for patients with BPI.

CONCLUSIONS

Clinical initiatives to assess social determinants of health should consider a focus on Asian patients with BPI.

Economic Burden Associated With Untreated Mental Illness in Indiana

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcomes and Measures

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

Results

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

Conclusion and Relevance

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

Antimanic Efficacy, Tolerability, and Acceptability of Clonazepam: A Systematic Review and Meta-Analysis

(1) Background: The use of benzodiazepines for the treatment of acute mania remains prevalent. This systematic review and meta-analysis provides an updated assessment of Clonazepam's antimanic efficacy, tolerability, and acceptability. (2) Methods: A systematic search of multiple databases and clinical trial registries was conducted, aiming to identify any controlled studies of Clonazepam vs. placebo or any other pharmacotherapy for the treatment of acute mania. Pairwise meta-analytic evaluations were performed. (3) Results: Six studies were included with a total number of 192 participants, all of which were randomized controlled trials. Clonazepam may be superior to a placebo in the acute phase of treatment and no different to Lithium and Haloperidol in terms of efficacy, both acutely and in the medium to long term. Clonazepam may be an acceptable and well-tolerated treatment for acute mania, especially when used as an augmentation strategy. Comparisons were underpowered, with minimal sample sizes and only one study per comparison in many cases, thus limiting the generalizability of our findings and hindering firm clinical conclusions. (4) Conclusions: Given the prevalence of benzodiazepine use in current practice, more and larger studies are urgently needed.

Comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression in adults: a systematic review and network meta-analysis

BACKGROUND

Bipolar depression constitutes a major public health problem due to its substantial burden of disease. Although pharmacological interventions are available, guidelines required updated evidence synthesis to improve their current recommendations. In order to inform evidence-based prescribing, we investigated the comparative efficacy and tolerability of pharmacological interventions for acute bipolar depression.

METHODS

We conducted a systematic review and network meta-analysis. We searched for randomised controlled trials comparing pharmacological interventions with each other or placebo in adults with acute bipolar depression (type I, type II, or not otherwise specified), excluding those with substance misuse, unipolar depression, or schizophrenia, in MEDLINE, Embase, PsycINFO, Google Scholar, Cochrane Library, Web of Knowledge, CINAHL, and LILACS from database inception up to April 13, 2023. Criteria for eligibility were a duration of 2-16 weeks with masked outcome assessments, and we included combination, add-on design, and monotherapy studies. The co-primary outcomes were depressive symptoms, examined with standardised mean differences (SMDs), and manic switch, examined with odds ratios (ORs). We also investigated dropouts due to any reason, inefficacy, adverse events, and important side-effects as secondary outcomes. The confidence in the evidence was evaluated using Confidence-In-Network-Meta-Analysis (CINeMA). The study was registered with PROSPERO, CRD42020171726.

RESULTS

We analysed data from 101 randomised controlled trials covering 20 081 participants, 8063 men (41·7%) and 11 263 women (58·3%; sex not available in four studies), mean age 41·0 years (range of means 28·7-53·6 years), and 68 medications and placebo. Ethnicity data were not available. With moderate confidence in the evidence, olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were more efficacious than placebo in reducing depressive symptoms, with SMDs ranging from 0·41 (95% CI 0·19-0·64) for olanzapine plus fluoxetine to 0·16 (0·03-0·29) for lamotrigine. Several other drugs might also be efficacious, but the confidence in the evidence was very low to low. Antidepressants as a class seem to be efficacious, but had a higher risk for manic switch compared to antipsychotics. Medications differed in their side-effect profiles.

INTERPRETATION

This is, to our knowledge, the largest network meta-analysis of pharmacotherapy for bipolar depression to date. Olanzapine plus fluoxetine, quetiapine, olanzapine, lurasidone, lumateperone, cariprazine, and lamotrigine were found to be more efficacious than placebo in adults with acute bipolar depression, with good confidence in the evidence, and to differ in their side-effect profiles. These findings can inform evidence-based care and the development of treatment guidelines internationally.

FUNDING

None.

De-Salazar P, Alegría M. Association of sociocultural stressors with bipolar disorder onset in Puerto Rican youth growing up as members of a minoritized ethnic group: results from the Boricua Youth Longitudinal Study

Background

The development of bipolar disorder is currently explained by a complex interaction of genetic and environmental factors. Less is known regarding the influence of sociocultural factors. This study aims to evaluate the incidence and impact of sociocultural factors on bipolar disorder onset in two comparable samples of youth growing up in different social settings.

Methods

We leveraged data from two urban population-based cohorts representative of Puerto Rican children growing up in either San Juan (Puerto Rico) or the South Bronx (NYC) and followed up for 17 years. Bipolar disorder diagnoses were based on retrospective self-reports on the World Health Organization Composite International Diagnostic Interview. We used a causal inference approach to estimate associations of sociocultural factors with bipolar disorder onset after adjusting for potential confounders.

Findings

We found that South Bronx children, who grew up as a minoritized group, had twice the risk of bipolar disorder onset as young adults, with an incidence rate of 2.22 new cases per 1000 person-years compared to 1.08 new cases in San Juan (incidence rate difference, 1.13; 95% CI, 0.09-1.20). After adjusting for potential confounders, South Bronx children had the same lifetime hazard of bipolar disorder onset compared to San Juan children. However, our analysis demonstrated that caregivers' exposure to societal cultural stress partially explained the increased risk of bipolar disorder onset in the South Bronx, in addition to the potential contribution of genetics.

Interpretation

Our results provide evidence that societal cultural stress can increase the risk of lifetime bipolar disorder onset in youth growing up as a minoritized group. Addressing stress in minoritized groups might reduce the risk of bipolar disorder onset.

Funding

The Boricua Youth Study has been supported by the National Institutes of HealthMH56401, MH098374, DA033172, and AA020191. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Inpatient prescribing patterns of long-acting injectables and their oral or short-acting injectable equivalent formulations

Background: Long-acting injectable (LAI) antipsychotics (APs) each have an oral equivalent formulation, while aripiprazole, olanzapine, and ziprasidone each also have a short-acting injectable (SAI) equivalent formulation. Inpatient prescribing patterns of LAIs and their oral/SAI equivalents are less characterized in populations other than Medicaid, Medicare, and Veterans Affairs populations. Mapping out inpatient prescribing patterns remains an important first step to ensure appropriate use of antipsychotics during this critical juncture of patient care prior to discharge. This study determined inpatient prescribing patterns of first- (FGA) and second-generation antipsychotic (SGA) LAIs and their oral/SAI formulations. Methods: This was a large retrospective study using the Cerner Health Facts® database. Hospital admissions due to schizophrenia, schizoaffective disorder, or bipolar disorder from 2010 to 2016 were identified. AP utilization was defined as the proportion of inpatient stays during which at least 1 AP was administered to the total number of inpatient visits over the observed period. Descriptive analyses were used to determine prescribing patterns for APs. Chi-square tests were used to determine utilization differences across years. Results: 94,989 encounters were identified. Encounters during which oral/SAI of SGA LAIs were administered were most common (n = 38,621, 41%). Encounters during which FGA LAIs or SGA LAIs were administered were the least common (n = 1,047, 1.1%). Prescribing patterns differed across years (p < 0.05) within the SGA LAI subgroup analysis (N = 6,014). Paliperidone palmitate (63%, N = 3,799) and risperidone (31%, N = 1,859) were the most frequently administered. Paliperidone palmitate utilization increased from 30% to 72% (p < 0.001), while risperidone utilization decreased from 70% to 18% (p < 0.001). Conclusions: Compared with their oral or SAI formulations, LAIs were underutilized from 2010 to 2016. Among SGA LAIs, the prescribing patterns of paliperidone palmitate and risperidone changed significantly.

Cigarette smoking and risk of suicide in bipolar disorder: a systematic review

Objective

Bipolar disorder (BD) is a highly prevalent, chronic and recurrent mental illness. The smoking rates in patients with BD are much higher than those of the general population, and BD is associated with an increased risk of suicide. An association between smoking and suicidal behavior has been found in the general population, this systematic review examines whether there is evidence of an association between smoking and suicide behavior in patients with BD.

Method

A database search was carried out in Medline, Embase, The Cochrane Library, Scopus, and Web of Science, updated until December 31st, 2021, according to the 2020 PRISMA guidelines. We identified prospective and retrospective studies that included patients diagnosed with BD types I, II, and not otherwise specified, and in which smoking and suicidal behavior were correlated. Articles that focused exclusively on other mental disorders were excluded. The Ottawa-Newcastle scale was used to assess the methodological quality of the included articles.

Results

Fifteen articles (n = 7,395) met all the inclusion criteria. In nine of these articles, the authors found an association between smoking and suicidal behavior in BD, while in the remaining six articles, this association was not found. A great deal of variability was observed between articles, particularly in the measurement of suicidal behavior and tobacco consumption. The risk of bias, as assessed by the NOS, was high for most of the included articles, except for two papers, whose risk was low.

Conclusion

It was not possible to establish a clear relationship between tobacco use and the risk of suicide in BD patients due to the heterogeneity of the articles included in this systematic review, which had different sample sizes and methodological issues. However, both conditions are highly prevalent and have a negative impact on the prognosis of BD. Therefore, a systematic approach is needed, based on accurate measurement of a patient's smoking habits and their risk of suicidal behavior, in order to establish an appropriate therapeutic plan.

Additional information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors and was registered on PROSPERO with the CRD42022301570 on January 21th 2022.

Assessment of Disruptive Life Events for Individuals Diagnosed With Schizophrenia or Bipolar I Disorder Using Data From a Consumer Credit Reporting Agency

Importance

There is a dearth of population-level data on major disruptive life events (defined here as arrests by a legal authority, address changes, bankruptcy, lien, and judgment filings) for patients with bipolar I disorder (BPI) or schizophrenia, which has limited studies on mental health and treatment outcomes.

Objective

To conduct a population-level study on disruptive life events by using publicly available data on disruptive life events, aggregated by a consumer credit reporting agency in conjunction with electronic health record (EHR) data.

Design, Setting, and Participants

This study used EHR data from 2 large, integrated health care systems, Kaiser Permanente Southern California and Henry Ford Health. Cohorts of patients diagnosed from 2007 to 2019 with BPI or schizophrenia were matched 1:1 by age at analysis, age at diagnosis (if applicable), sex, race and ethnicity, and Medicaid status to (1) an active comparison group with diagnoses of major depressive disorder (MDD) and (2) a general health (GH) cohort without diagnoses of BPI, schizophrenia, or MDD. Patients with diagnoses of BPI or schizophrenia and their respective comparison cohorts were matched to public records data aggregated by a consumer credit reporting agency (98% match rate). Analysis took place between November 2020 and December 2022.

Main Outcomes and Measures

The differences in the occurrence of disruptive life events among patients with BPI or schizophrenia and their comparison groups.

Results

Of 46 167 patients, 30 008 (65%) had BPI (mean [SD] age, 42.6 [14.2] years) and 16 159 (35%) had schizophrenia (mean [SD], 41.4 [15.1] years). The majoriy of patients were White (30 167 [65%]). In addition, 18 500 patients with BPI (62%) and 6552 patients with schizophrenia (41%) were female. Patients with BPI were more likely to change addresses than patients in either comparison cohort (with the incidence ratio being as high as 1.25 [95% CI, 1.23-1.28]) when compared with GH cohort. Patients with BPI were also more likely to experience any of the financial disruptive life events with odds ratio ranging from 1.15 [95% CI, 1.07-1.24] to 1.50 [95% CI, 1.42-1.58]). The largest differences in disruptive life events were seen in arrests of patients with either BPI or schizophrenia compared with GH peers (3.27 [95% CI, 2.84-3.78] and 3.04 [95% CI, 2.57-3.59], respectively). Patients with schizophrenia had fewer address changes and were less likely to experience a financial event than their matched comparison cohorts.

Conclusions and Relevance

This study demonstrated that data aggregated by a consumer credit reporting agency can support population-level studies on disruptive life events among patients with BPI or schizophrenia.

Job retention for people with bipolar disorder: A qualitative analysis

At least half of people with bipolar disorder, whose global prevalence is greater than 1% of the general population, do not have a stable occupation. The objective of this study is to identify the factors perceived by bipolar people as having an impact on retention in employment. Semi-directed individual interviews were offered to subjects with bipolar disorder, of working age, who had been seen by three different hospital departments in the south of France. These people had to be medically stable and have at least one occupational experience. Each interview was recorded and transcribed manually and then analyzed according to a thematic classification of verbatims. Nineteen people participated in the interviews. Three major themes identified were classified into intrinsic (working routine and working environment) and extrinsic (external aids) factors for the bipolar person. The majority believe that working regular hours is a balancing factor. For everyone, night work and stress factors can lead to relapses. All stressed the need to destigmatize the disease. Most believe that it is necessary to develop employment support organizations specific to mental illnesses. This research helps to inform people with bipolar disorder about the occupational factors that help balance their condition. Personalized multidisciplinary care pathways involving occupational medicine must be developed in order to promote the balance of the disease and job retention.

The economic and humanistic burden of bipolar disorder in adults in the United States

BACKGROUND

Bipolar disorder is associated with functional impairment and diminished health-related quality of life (HRQoL). The purpose of this study was to estimate the annual per patient direct healthcare costs, indirect costs, and HRQoL of patients with bipolar disorder by depressive symptom severity and overall compared to the general population in the US.

METHODS

This cross-sectional study used self-reported data from the 2020 US National Health and Wellness Survey. Adult respondents who reported bipolar disorder symptoms in the past 12 months and/or a diagnosis of bipolar disorder were identified (bipolar disorder cohort) and were further classified by depressive symptom severity based on Patient Health Questionnaire (PHQ-9) scores (none/mild = 0-9, moderate = 10-14, severe = 15-27). Annualized direct healthcare costs and indirect costs were calculated from 6-month healthcare resource utilization and work productivity, respectively. A general population cohort was constructed using 2:1 propensity score matching. Multivariate regression models of all-cause hospitalizations in the past 6 months, annualized direct healthcare costs, annualized indirect costs, and HRQoL (eg, EuroQol 5-Dimension Health Questionnaire (EQ-5D)) controlled for confounders (demographic and clinical characteristics).

RESULTS

Of 3583 adults meeting pre-specified criteria for bipolar disorder, 1401 (39.1%) reported none/mild, 889 (24.8%) moderate, and 1293 (36.1%) severe depressive symptom severity. Additionally, 3285 (91.7%) were matched to 6570 adults in the general population. Compared to the general population, adjusted mean hospitalizations (0.53 vs. 0.30), annualized per patient direct healthcare costs ($20,846 vs. $11,391), and indirect costs ($14,795 vs. $9274) were significantly greater for the bipolar disorder cohort (all p < 0.001); adjusted HRQoL (EQ-5D: 0.69 vs. 0.79) was significantly worse (p < 0.001). By depressive symptom severity, adjusted mean hospitalizations (none/mild = 0.30, moderate = 0.50, severe = 0.46), direct healthcare costs ($14,389, $22,302, $21,341), and indirect costs ($10,799, $17,109, $18,470) were significantly greater for moderate and severe compared to none/mild depressive symptom severity (all p < 0.01); adjusted HRQoL (EQ-5D: 0.77, 0.67, 0.59) was significantly worse (p < 0.001).

CONCLUSIONS

Among respondents with bipolar disorder, those with moderate to severe depression had greater direct healthcare costs and indirect costs as well as worse HRQoL than those with mild or no depressive symptoms. Treatment targeting reduction in depressive symptoms may reduce the economic and humanistic burden of bipolar disorder.

Triggers for acute mood episodes in bipolar disorder: A systematic review

OBJECTIVES

To identify triggers of acute mood episodes in bipolar disorder (BD).

METHODS

We performed a systematic review in the following databases: Pubmed, Embase, and PsycInfo following the preferred reporting items for systematic reviews and meta-analysis guidelines. The systematic search encompassed all relevant studies published until May 23rd, 2022.

RESULTS

A total of 108 studies (case reports/case series, interventional, prospective and retrospective studies) were included in the systematic review. While several decompensation triggers were identified, pharmacotherapy was the one with the largest body of evidence, particularly the use of antidepressants as triggers of manic/hypomanic episodes. Other identified triggers for mania were brain stimulation, energy drinks, acetyl-l-carnitine, St. John's wort, seasonal changes, hormonal changes and viral infections. There is a relative paucity of evidence concerning triggers for depressive relapses in BD, with possible triggers including fasting, decreased sleep and stressful life events.

CONCLUSIONS

This is the first systematic review about triggers/precipitants of relapse in BD. Despite the importance of identification and management of potential triggers for BD decompensation, there is a lack of large observational studies addressing this topic, with most of the included studies being case reports/case series. Notwithstanding these limitations, antidepressant use is the trigger with the strongest evidence for manic relapse. More studies are needed to identify and manage triggers for relapse in BD.

Brain-derived Neurotrophic Factor and High Sensitive C-reactive Protein in Bipolar Depression and Unipolar Depression: The Practical Usage as a Discriminatory Tool

Objective

Brain-derived neurotrophic factor (BDNF) and high sensitive C-reactive protein (hs-CRP) have been reported to play roles in depression and bipolar disorder (BD). However, the probable discriminatory properties of these biologic markers are less investigated. We aimed to assess the serum BDNF and hs-CRP levels among Iranian patients with major depressive disorder (MDD) and BD during a depressive episode and investigate the optimum cut-off point for differential diagnosis of BD and MDD.

Methods

We recruited 30 patients with MDD, 30 with BD in depressive mood and 30 healthy comparators. Blood sample was taken from each participant to measure BDNF and hs-CRP levels. We also used receiver operating characteristic (ROC) curve analysis to find an optimal cut-off point for differentiating MDD from BD according to pre-defined variables.

Results

The mean age of total study population was 37.3 ± 5.0 years (males: 49%). BDNF was significantly lower in patients with BD, followed by MDD subjects and healthy controls 541.0 ± 601.0 pg/ml vs. 809.5 ± 433.3 pg/ml vs. 1,482.1 ± 519.8, respectively, p < 0.001). The area under curve of ROC curve analysis for BD versus MDD was 0.704 (95% confidence interval: 0.564-0.844, p = 0.007). We also found that the BDNF cut-off value of 504 could appropriately distinguished BD from MDD (sensitivity: 73%, specificity: 70%). No significant association were identified in terms of hs-CRP levels.

Conclusion

Patients suffering from BD had lowest BDNF levels compared to MDD or healthy adults and this biomarker could play a practical role differentiating MDD from BD. Several studies are required confirming our outcomes.

Total healthcare cost savings through improved bipolar I disorder identification using the Rapid Mood Screener in patients diagnosed with major depressive disorder

INTRODUCTION

Misdiagnosis of bipolar I disorder (BP-I) as major depressive disorder (MDD) leads to increased healthcare resource utilization and costs. The cost-effectiveness of the Rapid Mood Screener (RMS), a tool to identify BP-I in patients with depressive symptoms, was assessed in patients diagnosed with MDD presenting with depressive episodes.

METHODS

A decision-tree model of a hypothetical cohort of 1000 patients in a US health plan was used to estimate the number of correct diagnoses and overall total, direct healthcare costs over a 3-year timeframe for RMS-screened versus unscreened patients. Model inputs included the prevalence of BP-I in patients diagnosed with MDD, RMS sensitivity/specificity, and the cost of misdiagnosing BP-I as MDD.

RESULTS

Screening with the RMS resulted in 171, 159, and 143 additional correct BP-I or MDD diagnoses at Years 1, 2, and 3, respectively. Total healthcare plan cost savings were $1279 per patient in Year 1. Cumulative cost savings per patient for RMS screening versus no RMS screening were $2307 over 2 years and $3011 over 3 years. Scenario analyses showed that the RMS would remain cost-saving assuming a lower prevalence of BP-I (20% or 10%) versus the base case (24.3%).

CONCLUSION

The RMS is a cost-effective tool to identify BP-I in patients who would otherwise be misdiagnosed with MDD. Screening with the RMS resulted in cost-savings over 3 years, with model results remaining robust even with lower prevalence of BP-I and reduced RMS sensitivity assumptions.

Comparative efficacy, acceptability, and tolerability of adjunctive anti-inflammatory agents on bipolar disorder: A systemic review and network meta-analysis

OBJECTIVES

We performed a network meta-analysis (NMA) with up-to-date evidence to compare different anti-inflammatory agents to improve the treatment of bipolar disorder (BD) patients.

METHODS

Four databases (i.e., the Cochrane Library, Web of Science, PubMed, and Embase) were searched for randomized controlled trials (RCTs) published between 1995 and 2022 on the use of anti-inflammatory agents in the treatment of BD. A systematic review and NMA were conducted.

RESULTS

Adjunctive N-acetylcysteine (NAC) was superior to placebo for the treatment of BD according to the endpoint scale score (SMD -0.65, 95% confidence interval (CI): - 0.99 to - 0.31), response rate (odds ratio (OR) 3.42, 95% CI: 1.23-9.52), remission rate (OR 4.94, 95% CI: 1.03-41.38) and surface under the cumulative ranking curve (SUCRA) value of the endpoint scale score (0.84). Adjunctive nonsteroidal anti-inflammatory drugs (NSAIDs) were more favorable than placebo based on the remission rate (OR 3.93, 95% CI: 1.15-13.43) and were significantly more acceptable than other treatments (OR 0.60, 95% CI: 0.36-0.99). Adjunctive coenzyme Q10 (CoQ10) was superior to other agents in terms of the response rate (OR 18.85, 95% CI: 2.63-135.00), with a SUCRA value for the response rate of 0.90 and that for the remission rate of 0.71.

CONCLUSION

Adjunctive NAC is recommended for the treatment of BD. Adjunctive NSAIDs and CoQ10 are still seen as effective, but more high-quality clinical studies are needed to verify their efficacy. Other anti-inflammatory agents may not be recommended for clinical use at present. All anti-inflammatory agents demonstrated a good safety profile. We call for further research on the combined treatment of BD with different anti-inflammatory agents to be included in future trials.

Impact of COVID-19 pandemic on relapse of individuals with severe mental illness and their caregiver's burden

Background

The implementation of quarantine and social distancing measures to control the COVID-19 pandemic led to restrictions at the community level and most of in-person psychiatric services were discontinued. This situation could affect the psychopathology of the patients and the burden of their caregivers. The aim of this study was to investigate the effects of COVID-19 pandemic on people with severe mental illnesses (SMIs) and their caregivers' burden.

Method

The study sample consisted of 86 patients with severe mental illness and 86 caregivers. The mental status, relapse rate, and rehospitalization rate of the patients and the general health status and burden of caregivers were investigated in three waves, including before and 3 and 6 months after the COVID-19 pandemic.

Results

The relapse rate of the patients was 14%, 33.7%, and 43% (p = 0.000) and the rehospitalization rate was 4.7%, 7%, and 10.5% in waves 0, 1, and 2, respectively (p = 0.000). Most of the psychopathological scales increased in three waves (p = 0.000). The caregivers' burden and health condition worsened during the nine months of the study as well (p = 0.000).

Conclusion

The COVID-19 pandemic led to the exacerbation of symptoms and increased the relapse rate in people with SMIs. It also worsened the caregivers' condition. People with severe mental illnesses (SMIs) and their caregivers are one of the most vulnerable groups on which the COVID-19 pandemic had a marked negative effect.

A retrospective study of psychotropic drug treatments in bipolar disorder at acute and maintenance episodes

BACKGROUND

Bipolar disorder (BD) is predominantly treated with psychotropic drugs, but BD is a complex medical condition and the contribution of psychotropic drugs is not clear. The objectives of this study are: (1) to present psychotropic drugs used in patients with BD; (2) to access changes of psychotropic drug treatments in acute and maintenance episodes.

METHODS

The study retrospectively evaluated the medical records of inpatients in the Ningbo Kangning Hospital from January 2019 to December 2019. The medical history of each subject was collected completely, including sociodemographic (gender, age, marital status, and so on) and clinical characteristics at baseline and within 12 months of admission.

RESULTS

The study ultimately included 204 patients with BD. After 12 months, 73.0% of the patients still took drugs. Mood stabilizers (72-90%) and antipsychotics (77-95%) were still the most important drugs in patients with BD. Antidepressants (34-40%) and benzodiazepines (20-34%) were the other frequently used drug classes. For mood stabilizers, 40-56% of patients were prescribed lithium. For antipsychotic, 54-65% of patients were prescribed quetiapine. Sertraline (6-9%) and fluoxetine (5-9%) were the antidepressant that most frequently prescribed. Lorazepam (10-18%) was the most commonly used benzodiazepine. In psychotropic polypharmacy, the most frequently taken was mood stabilizer plus antipsychotic co-treatment, about 36-44% of all patients. A total of 35-48% of patients treated by two psychotropic drugs and 24-36% received three.

CONCLUSION

The first 6 months after treatment is very important to medication adherence. Mood stabilizers and antipsychotic remained the primary treatment for BD. Antipsychotic is on the rise in the treatment of BD.

Treating Bipolar Disorder in Primary Care: Diagnosis, Pharmacology, and Management

Bipolar disorder is a chronic mental illness associated with early mortality, elevated risk of comorbid cardiovascular disease, enormous burden of disability, and large societal costs. Patients often seek treatment for symptoms of bipolar disorder in the primary care setting but are frequently misdiagnosed. This article provides primary care providers with an evidence-based approach to the screening, diagnosis, and pharmacological management of bipolar disorder. Guidance is also provided for helping patients connect with higher levels of specialty psychiatric care when clinically indicated.

Cognitive profiles in bipolar I disorder and associated risk factors: Using Wechsler adult intelligence scale—IV

Background

Despite the growing evidence of cognitive impairments in bipolar disorder (BD), little work has evaluated cognitive performances utilizing the latest version of the Wechsler Intelligence Scale-IV (WAIS-IV), which is one of the most widely used neurocognitive assessments in clinical settings. Furthermore, clinical characteristics or demographic features that negatively affect the cognitive functioning of BD were not systematically compared or evaluated. Accordingly, the present study aimed to examine the cognitive profile of bipolar I disorder (BD-I) patients and associated risk factors.

Methods

Participants included 45 patients, diagnosed with BD-I, current or most recent episode manic, and matching 46 healthy controls (HC). Cognitive performance was evaluated via WAIS-IV, and clinical characteristics of the BD-I group were examined via multiple self- and clinician-report questionnaires.

Results

Multivariate analysis of covariance (MANCOVA) results indicated that the BD-I group demonstrated significantly poorer performance compared to the HC group in subtests and indexes that reflect working memory and processing speed abilities. Redundancy analysis revealed that overall symptom severity, manic symptom severity, and anxiety were significant predictors of cognitive performance in BD-I, while age of onset, past mood disorder history, depression severity, and impulsiveness showed comparatively smaller predictive values.

Conclusion

The current study suggests cognitive deterioration in the cognitive proficiency area while generalized ability, including verbal comprehension and most of the perceptual reasoning skills, remain intact in BD-I. The identified risk factors of cognitive performance provide specific clinical recommendations for intervention and clinical decision-making.

Readmissions, costs, and duration to subsequent outpatient visit after hospital discharge among Medicaid beneficiaries utilizing oral versus long-acting injectable antipsychotics in bipolar disorder or schizophrenia

BACKGROUND

Long-acting injectable antipsychotics (LAIs) may reduce hospitalizations versus oral formulations (OAP) in bipolar disorder (BP) and schizophrenia/schizoaffective disorder (SCZ), but the impact on time to outpatient follow-up is less understood.

OBJECTIVES

To assess hospital readmissions and medical costs among Medicaid beneficiaries with BP or SCZ utilizing OAP or LAI SGAs.

METHODS

Cross-sectional and longitudinal analyses utilized comprehensive administrative claims of Oklahoma Medicaid beneficiaries (≥18 years) with BP or SCZ between 1 January 2013 and 31 December 2017. Readmissions, total direct medical costs, and psychiatry-related outpatient visits were assessed via generalized linear models and generalized estimating equations, controlling for demographic and clinical covariates.

RESULTS

Among 2523 included members, LAI utilization was associated with 1.50 and 1.73 times higher odds of any hospitalization and any readmission, respectively (p < .05). Cases involving both BP and SCZ were associated with a 2.40 times higher odds of any readmission, 2.26 times higher number of readmissions, and 24.5% higher costs (p < .001). Of the 468 members with a subsequent psychiatry-related outpatient visit, LAIs were associated with a 23.9% shorter duration to outpatient visit and 16.4% lower costs (p < .05).

CONCLUSION

In contrast to prior studies, this real-world investigation noted higher hospitalizations and readmissions among LAIs relative to OAP medications, but among members with a hospitalization or ED visit, LAIs were associated with shorter durations to outpatient visits and lower costs. Those with diagnoses of both BP with SCZ had higher odds of any readmission, number of readmissions, and costs relative to those with bipolar disorder alone and may be a key target for interventions.

The effect of mindfulness-based cognitive therapy on rumination and a task-based measure of intrusive thoughts in patients with bipolar disorder

Background

Preliminary evidence suggests that Mindfulness-Based Cognitive Therapy (MBCT) is a promising treatment for bipolar disorder (BD). A proposed working mechanism of MBCT in attenuating depressive symptoms is reducing depressive rumination. The primary aim of this study was to investigate the effect of MBCT on self-reported trait depressive rumination and an experimental state measure of negative intrusive thoughts in BD patients. Exploratively, we investigated the effect of MBCT on positive rumination and positive intrusive thoughts.

Methods

The study population consisted of a subsample of bipolar type I or II patients participating in a multicenter randomized controlled trial comparing MBCT + treatment as usual (TAU) (N = 25) to TAU alone (N = 24). Trait depressive rumination (RRS brooding subscale) and intrusive thoughts (breathing focus task (BFT)) were assessed at baseline (full subsample) and post-treatment (MBCT + TAU; n = 15, TAU; n = 15). During the BFT, participants were asked to report negative, positive and neutral intrusive thoughts while focusing on their breathing.

Results

Compared to TAU alone, MBCT + TAU resulted in a significant pre- to post-treatment reduction of trait depressive rumination (R² = .16, F(1, 27) = 5.15, p = 0.031; medium effect size (f² = 0.19)) and negative intrusive thoughts on the BFT (R² = .15, F(1, 28) = 4.88, p = 0.036; medium effect size (f² = 0.17)). MBCT did not significantly change positive rumination or positive intrusive thoughts.

Conclusions

MBCT might be a helpful additional intervention to reduce depressive rumination in BD which might reduce risk of depressive relapse or recurrence. Considering the preliminary nature of our findings, future research should replicate our findings and explore whether this reduction in rumination following MBCT indeed mediates a reduction in depressive symptoms and relapse or recurrence in BD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00269-1.

Using mHealth to improve adherence and reduce blood pressure in individuals with hypertension and bipolar disorder (iTAB-CV): study protocol for a 2-stage randomized clinical trial

BACKGROUND

Cardiovascular disease in individuals with mental health conditions such as bipolar disorder is highly prevalent and often poorly managed. Individuals with bipolar disorder face significant medication adherence barriers, especially when they are prescribed multiple medications for other health conditions including hypertension. Poor adherence puts them at a disproportionate risk for poor health outcomes. As such, there is a need for effective interventions to improve hypertension medication adherence, particularly in patients that struggle with adherence due to mental health comorbidity.

METHODS

This 5-year project uses a 2-stage randomized controlled trial design to evaluate a brief, practical adherence intervention delivered via interactive text messaging (iTAB-CV) along with self-monitoring of medication taking, mood, and home blood pressure (N = 100) compared to self-monitoring alone (N = 100). Prior to randomization, all participants will view an educational video that emphasizes the importance of medication for the treatment of hypertension and bipolar disorder. Those randomized to the texting intervention will receive daily text messages with predetermined content to address 11 salient domains as well as targeted customized messages for 2 months. This group will then be re-randomized to receive either a high (gradual taper from daily to weekly texts) or low booster (weekly texts) phase for an additional 2 months. All participants will be monitored for 52 weeks. The primary outcomes are systolic blood pressure and adherence to antihypertensive medication as determined by a self-reported questionnaire and validated with an automated pill-monitoring device. Secondary outcomes include adherence to bipolar disorder medications, psychiatric symptoms, health status, self-efficacy for medication-taking behavior, illness beliefs, medication attitudes, and habit strength.

DISCUSSION

This study specifically targets blood pressure and mental health symptom control in people with bipolar and includes implementation elements in the study design intended to inform future scale-up. Promising pilot data and a theoretical model, which views sustained medication-taking behavior in the context of habit formation, suggests that this remotely delivered intervention may help advance care for this high-risk population and is amenable to both scale up and easy adaptation for other groups with poor medication adherence.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov ( NCT04675593 ) on December 19, 2020.

Direct medical cost of bipolar disorder: Insights from the FACE-BD longitudinal cohort

BACKGROUND

Bipolar disorder (BD) is a severe chronic psychiatric disorder affecting 0.5 to 1% of the population worldwide. To date, most studies have estimated the cost of BD via information sourced from insurance claims with limited information on clinical characteristics and course of BD. The aims of this study are (i) to estimate the direct healthcare cost associated with BD and to identify contributing factors and (ii) to study the evolution of cost during a two-year follow-up period.

METHOD

We analyzed a sample of 1116 individuals with BD included in the Advanced Centers of Expertise in Bipolar Disorder cohort. We estimated the direct healthcare cost per year and per patient, and we identified the clinical features of patients with BD associated with higher direct healthcare costs. In a subsample of patients followed up for two years centers of expertise for BD, we studied the evolution of direct healthcare cost.

RESULTS

The average cost of bipolar disorder was € 6910 per year and per patient. Clinical features of BD, sociodemographic characteristics, and associated addiction were associated with higher direct healthcare costs. In the subsample of patients followed-up for two years, direct healthcare cost dropped by more than 50%, strongly suggesting the beneficial effect of specialized care organization.

LIMITATION

We did not estimate indirect healthcare and intangible costs.

CONCLUSION

Our study investigates the cost of BD and its evolution in a deeply phenotyped longitudinal sample. Cost-utility and cost-effectiveness analyses are required to inform resource allocation decisions and to promote innovative healthcare organizations.

Temporal relationships of ecological momentary mood and actigraphy-based sleep measures in bipolar disorder

Sleep disturbances are a key feature of bipolar disorder (BD), and poor sleep has been linked to mood symptoms. Recent use of ecological momentary assessment (EMA) has allowed for nuanced exploration of the sleep-mood link; though, the scale and directionality of this relationship is still unclear. Using EMA, actigraphy, and self-reported sleep measures, this study examines the concurrent and predictive relationships between sleep and mood. Participants with BD (n = 56) wore actigraphy devices for up to 14 days and completed validated scales and daily EMA surveys about mood and sleep quality. Linear mixed models were used to examine overall and time-lagged relationships between sleep and mood variables. EMA mood ratings were correlated with validated rating scales for depression, mania, anxiety, and impulsivity. Poor self-reported sleep quality was associated with worse overall ratings of sadness and anger. Worse self-reported sleep quality was associated with greater sadness the following day. Higher daytime impulsivity was associated with worse sleep quality the following night. Exploratory analyses found relationships between worse and more variable mood (sadness, anger, and impulsivity) with worse and more variable sleep that evening (efficiency, WASO, and sleep onset time). The sample size was modest, fairly homogenous, and included mainly euthymic persons with BD. EMA-based assessments of mood and sleep are correlated with validated scale scores and provide novel insight into intra-individual variability. Further work on the complex two-way interactions between sleep and mood is needed to better understand how to improve outcomes in BD.

Affective disorders: eliminate WArning signs and REstore functioning-AWARE-a randomised controlled multimodule intervention study, presentation of design and intervention

INTRODUCTION

Affective disorders are associated with impaired overall functioning and quality of life (QoL). Despite different medical and psychological treatment options, the prognosis remains largely unchanged. Consequently, the field needs new intervention strategies especially targeting patient groups with impaired functioning. This study aims to improve functioning and QoL in patients with affective disorders using a comprehensive 360° intervention.

METHODS AND ANALYSIS

Affective disorders: eliminate WArning signs And REstore (AWARE) functioning is a randomised, controlled, parallel-group design study. Participants will be 120 outpatients, men or women, aged 18-65 years, with a diagnosis of bipolar disorder or major depressive disorder. Inclusion requires an objectively rated impaired functioning defined as a score ≥11 according to the Functioning Assessment Short Test. Participants will be randomised to 6-month AWARE intervention or treatment as usual (TAU). The AWARE intervention is a 360° multimodal intervention based on the International Classification of Functioning Brief Core Set for bipolar and unipolar disorder targeting functioning.The primary outcome is improvement of observation-based activities of daily living (ADL) ability using Assessment of Motor and Process Skills. Secondary outcomes are changes from baseline to endpoint in functioning, QoL, stress, cognition and physical health.Our hypothesis is that the AWARE treatment in comparison with TAU will improve observed ability to perform ADL, patients self-perceived level of functioning and QoL.Status: currently recruiting patients.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from The Regional Ethics Committee in the Capital Region of Denmark. All patients will be provided oral and written information about the trial before informed consent is obtained. The study results will be disseminated by peer-review publications. If the present AWARE intervention shows beneficial effects, the goal is to use it as a template for future interventions addressing disability in patients with affective disorders as well as for patients within other diagnostic categories.

TRIAL REGISTRATION NUMBER

NCT04701827; Clinicaltrials.gov.

Effect of exercise as adjuvant to energy-restricted diets on quality of life and depression outcomes: a meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Obesity and related co-morbidities lead to a decrease in health-related quality of life (HRQOL) and mood. Lifestyle strategies may improve these outcomes. However, the efficacy of exercise in conjunction with a weight-loss diet on HRQOL and mood is unclear. The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to examine whether the addition of exercise to energy-restricted dietary programs improves HRQOL and mood status when compared with energy-restricted diets alone in overweight and obese adults.

METHODS

Eligible RCTs were identified by searching PubMed/MEDLINE, EMBASE, ISI (Web of sciences), Scopus, and Google Scholar up to April 2021. Summary effects were derived using a random-effects model. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

The meta-analysis revealed that an energy-restricted diet plus exercise compared with an energy-restricted diet alone had no significant effects on depression (n = 6, hedges'g = - 0.04, 95% CI: - 0.28,0.20), MOS 36-Item Short-Form Health Survey (SF-36)-physical component summary scores (n = 8, weighted mean difference (WMD) = 1.51, 95% CI: - 0.16, 3.18), SF36-mental component summary scores (n = 7, WMD = 0.64, 95% CI: - 1.00, 2.28), and HRQOL disease-specific questionnaire scores (n = 5, hedges'g = 0.16, 95% CI: - 0.09, 0.40). The GRADE revealed that the quality of evidence was low for disease-specific HRQOL scores, and depression status; and high for physical and mental health assessed by SF-36.

CONCLUSION

In our sample of overweight and obese adults, no beneficial effect of adding exercise to an energy-restricted diet was found in terms of HRQOL and Depression.

Assessing the Use of Data Systems to Estimate Return-on-Investment of Behavioral Healthcare Interventions: Opportunities and Barriers

To improve access to and quality of affordable behavioral healthcare, there is a need for more research to identify which interventions can generate long-term, societal return-on-investment (ROI). Barriers to ROI studies in the behavioral health sector were explored by conducting semi-structured interviews with individuals from key stakeholder groups at state and national behavioral health-related organizations. Limited operating budgets, state-based payer systems, the lack of financial support, privacy laws, and other unique experiences of behavioral health providers and patients were identified as important factors that affect the collection and utilization of data. To comprehensively assess ROI of interventions, it is necessary to improve standardization and data infrastructure across multiple health and non-health systems and clarify or address legal, regulatory, and commercial conflicts.

Reliability and Validity of the Bipolar Prodrome Symptom Interview and Scale-Full Prospective in Its Turkish Translation

Editors' Note: The Editors would like to address issues related to the acceptance of this manuscript. The original manuscript referenced the study tool as the Bipolar Prodrome Symptom Interview Scale-Prospective (BPSS-P). After the manuscript's initial acceptance, the authors requested a revision of the tool name to Bipolar Prodrome Symptom Interview Scale-Full Perspective (BPSS-FP). When this request was made, the original acceptance was rescinded, and the authors were asked to formally revise and resubmit the manuscript with an explanation for the change. This revision and subsequent review led to the final acceptance of the manuscript. The authors have assured us that the tool used in the manuscript was the BPSS-FP (version 5) as opposed to abbreviated forms of this tool that are also used in research (e.g., Bipolar Prodrome Symptom Scale-Abbreviated Screen for Patients (BPSS-AS-P). Background: No scale exists to assess patients at-risk for bipolar disorder (BD) in Turkey. We aimed to assess the psychometric properties of the Turkish version of the Bipolar Prodrome Symptom Interview and Scale-Full Prospective (BPSS-FP). Method: Psychiatric service users aged 11-18 years old were interviewed using the BPSS-FP translated into Turkish and the Kiddie Schedule for Affective Disorders and Schizophrenia. Youth with major depressive disorder (MDD, n = 63), bipolar-spectrum disorder (n = 47), and healthy controls (n = 122) were included. Cronbach's alpha was calculated to assess internal consistency. The Young Mania Rating Scale (YMRS) and Children's Depression Rating Scale-Revised (CDRS-R) were administered to test convergent/discriminant validity. Discriminant validity was further tested using one-way ANOVA and "receiver operating characteristic" (ROC) curves. Inter-rater reliability was tested using correlation coefficients. Findings: Across 232 youth, Cronbach's alpha values were 0.932 for the BPSS-FP total score, 0.878 for the Mania Symptom Index, 0.887 for the Depression Symptom Index, and 0.797 for the General Symptom Index. Correlation coefficients for inter-rater reliability were high for the Mania Symptom Index (r = 0.989), Depression Symptom Index (r = 0.973), and General Symptom Index (r = 0.981). There were high correlations between the BPSS-FP Mania Symptom Index subscore and YMRS (r = 0.732), and the BPSS-FP Depression Symptom Index subscore and CDRS-R (r = 0.754), whereas cross-polarity correlations were non-significant. ROC analysis cut-off value was ≥21 for the BPSS-FP Mania Symptom Index between patients with BD and MDD (specificity = 85.7%, sensitivity = 78.7%). Conclusion: The Turkish version of the BPSS-FP has good psychometric properties and can be used in research. Longitudinal studies are needed to confirm the predictive value of the BPSS-FP.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Index depressive episode and antidepressant exposure were associated with illness characteristics of pediatric bipolar disorder

OBJECTIVE

Pediatric bipolar disorder (PBD) is a serious, recurrent disorder leading to severe functional impairment. As a first mood episode, index episode could affect the long-term course of the illness. This study aimed to investigate the clinical characteristics of youth with PBD from our multicenter, nationwide, naturalistic follow-up samples and to identify (i) the effects of index mood episode and (ii) the effect of previous antidepressant treatments on the age at mania onset of PBD.

METHOD

The study sample consisted of 271 youth with BD-I followed by the child and adolescent psychiatry clinics of seven different university hospitals and three research state hospitals, representing six geographic regions across Turkey. All diagnoses were made according to structured interviews, and all data were retrospectively obtained from clinical records by the clinicians.

RESULTS

When patients with index depressive/mixed episodes (IDE, n=129) and patients with index (hypo)manic episodes (IME, n=142) were compared, the total number of mood episodes and rapid cycling feature were significantly higher in the IDE group than in the IME group. The Cox regression analysis adjusted for sociodemographic and illness characteristics revealed female adolescents in the IDE group treated with antidepressants were more likely to have an earlier onset of mania (hazard ratio=2.03, 95% confidence interval=1.31-3.12, p=0.001).

CONCLUSION

This is the first large-scale nationwide follow-up study in Turkey that indicated prior antidepressant treatments were associated with an earlier onset of mania in youth, particularly in adolescent females. Larger prospective studies are needed to identify neurodevelopmental processes underlying PBD and initiate prevention approaches.

Genetic and Epigenetic Markers of Lithium Response

The mood stabilizer lithium represents a cornerstone in the long term treatment of bipolar disorder (BD), although with substantial interindividual variability in clinical response. This variability appears to be modulated by genetics, which has been significantly investigated in the last two decades with some promising findings. In addition, recently, the interest in the role of epigenetics has grown significantly, since the exploration of these mechanisms might allow the elucidation of the gene–environment interactions and explanation of missing heritability. In this article, we provide an overview of the most relevant findings regarding the pharmacogenomics and pharmacoepigenomics of lithium response in BD. We describe the most replicated findings among candidate gene studies, results from genome-wide association studies (GWAS) as well as post-GWAS approaches supporting an association between high genetic load for schizophrenia, major depressive disorder or attention deficit/hyperactivity disorder and poor lithium response. Next, we describe results from studies investigating epigenetic mechanisms, such as changes in methylation or noncoding RNA levels, which play a relevant role as regulators of gene expression. Finally, we discuss challenges related to the search for the molecular determinants of lithium response and potential future research directions to pave the path towards a biomarker guided approach in lithium treatment.

Neural correlates of working memory function in euthymic people with bipolar disorder compared to healthy controls: A systematic review and meta-analysis

BACKGROUND

Bipolar disorders (BD) are serious mental health disorders that impacts on cognitive and social functioning. We aimed to systematically review and conduct a meta-analysis of fMRI correlates of working memory in euthymic people with BD compared to healthy participants.

METHOD

Web of Science, Embase and PubMed databases were systematically searched to identify studies which examined the fMRI correlates of working memory function in euthymic people with BD and healthy participants. Relevant demographic, behavioral and functional MRI (fMRI) data was qualitatively and quantitatively assessed, and the quality of the included studies evaluated. Comparable studies which used the same working memory task were included in a meta-analysis using Seed-Based D Mapping software (SDM).

RESULTS

Twenty-four studies were included in this systematic review. Consistent brain fMRI activity differences were found in key brain areas of the working memory network in euthymic people with BD compared to healthy participants including the ventromedial and dorsolateral prefrontal cortices. Cognitive performance was not significantly different between the two groups. Six studies were suitable to be included in the meta-analysis. There was no significant overlap in areas of brain activation after family-wise correction for multiple comparisons.

LIMITATIONS

Heterogeneity of task paradigms, small sample sizes and inherent difficulty in the interpretation of functional brain activity due to variations between studies were all limitations.

CONCLUSION

The differences in working memory related fMRI activity identified by this study between people with BD and healthy participants are consistent with existing literature reporting impaired working memory performance in BD. This was not accompanied by significant differences in cognitive performance in the reviewed studies, likely due to small sample sizes. Further studies are needed to investigate the relationship between differential brain activity and working memory performance in people with BD.

Designing and testing of a health-economic Markov model to assess the cost-effectiveness of treatments for Bipolar disorder: TiBipoMod

BACKGROUND

Bipolar disorder is an often recurrent mood disorder that is associated with a significant economic and health-related burden. Increasing the availability of health-economic evidence may aid in reducing this burden. The aim of this study is to describe the design of an open-source health-economic Markov model for assessing the cost-effectiveness of interventions in the treatment of Bipolar Disorders type I and II, TiBipoMod.

METHODS

TiBipoMod is a decision-analytic Markov model that allows for user-defined incorporation of both pharmacological and non-pharmacological interventions for the treatment of BD. TiBipoMod includes the health states remission, depression, (hypo)mania and death. Costs and effects are modeled over a lifetime horizon from a societal and healthcare perspective, and results are presented as the total costs, Quality-Adjusted Life Years (QALY), Life Years (LY), and incremental costs per QALYs and LYs gained.

RESULTS

Functionalities of TiBipoMod are demonstrated by performing a cost-utility analysis of mindfulness-based cognitive therapy (MBCT) compared to the standard of care. Treatment with MBCT resulted in an increase of 0.18 QALYs per patient, and a dominant incremental cost-effectiveness ratio per QALY gained for MBCT at a probability of being cost-effective of 71% when assuming a €50,000 willingness-to-pay threshold.

CONCLUSION

TiBipoMod can easily be adapted and used to determine the cost-effectiveness of interventions in the treatment in Bipolar Disorder type I and II, and is freely available for academic purposes upon request at the authors.

Chronic Stress in Bipolar Disorders Across the Different Clinical States: Roles of HPA Axis and Personality

INTRODUCTION

Chronic stress has been linked to the pathophysiology of bipolar disorder (BD); however, the underlying mechanism remains unclear. In BD patients, hypothalamic-pituitary-adrenal (HPA) axis activity is associated with stress. This study aimed to examine the relationship between HPA axis activity and BD symptoms in various clinical states, as well as how personality influences the process.

METHODS

This study investigated the differences in HPA axis activity among four BD states. We enrolled 813 BD patients in an 8-week longitudinal study to examine the relationship between HPA axis activity and symptom trajectories using dynamic temporal warping (DTW) analysis and an unsupervised machine learning technique. Furthermore, using mediation analyses, the relationship between the HPA axis, personality, and BD symptoms was investigated.

RESULTS

Analysis of variance (ANOVA) analysis showed that glucocorticoid cortisol (CORT) and adrenocorticotropin (ACTH) did not differ significantly among the four clinical states of BD. The DTW integrating clustering analysis revealed that the two clusters were optimal, with cluster 1 characterized by severe manic symptoms, which then improved, and cluster 2, characterized by milder manic severity, which also improved. The two clusters showed different ACTH levels (t = 2.289, p = 0.022), and logistic regression analysis revealed a slight positive association between ACTH levels and cluster 1. Furthermore, the mediation analysis indicated that ACTH influences curative efficacy via conscientiousness (βc =0.103, p=0.001).

DISCUSSION

In conclusion, we found that a higher level of ACTH is associated with severe manic symptoms, indicating a chronic stress response in BD patients. Additionally, the ACTH levels affect short-term BD curative efficacy via the mediation of conscientiousness, providing a psychotherapeutic strategy direction for BD.

The impact of lurasidone on functioning and indirect costs in adults with bipolar depression: a post-hoc analysis

OBJECTIVE

The aim of this post-hoc analysis was to assess the impact of lurasidone monotherapy on functional impairment, productivity, and associated indirect costs in patients with bipolar depression.

METHODS

Data were analyzed from a 6-week randomized, double-blind (DB; NCT00868699), placebo-controlled trial of lurasidone monotherapy and a 6-month open label extension (OLE; NCT00868959) study. Patients with bipolar depression who completed the 6-week DB trial were subsequently enrolled in the OLE. Analysis of the OLE was limited to patients who either continued lurasidone (LUR-LUR) or switched from placebo to lurasidone monotherapy (PBO-LUR). The Sheehan Disability Scale (SDS), which measures functional impairment and productivity, was collected at DB baseline, DB week 6/OLE baseline, OLE month 3, and OLE month 6. Annual indirect costs were calculated based on days lost or unproductive from work/school due to symptoms. Effect sizes (ES) in functioning and days lost/unproductive were reported for the DB trial and mean changes for the OLE.

RESULTS

A total of 485 patients were enrolled in the DB trial (lurasidone: n = 323; placebo: n = 162) and 316 were in the lurasidone monotherapy group during the OLE (LUR-LUR: n = 210; PBO-LUR: n = 106). In the DB trial, improvements in functioning (work: ES = 0.36, p = .0071; social: ES = 0.55, p < .0001; family: ES = 0.50, p < .0001) were significantly greater for lurasidone compared to placebo. Reductions in days lost (ES = 0.33, p = .0050) and unproductive (ES = 0.45, p = .0001) were significantly higher for lurasidone vs. placebo. This resulted in a greater reduction in indirect costs for lurasidone vs. placebo (least squares mean (standard error) = -$32,322 ($2,100) vs. -$20,091 ($2,838)). Improvements in functioning and productivity were sustained during the 6-month OLE for both LUR-LUR and PBO-LUR.

CONCLUSIONS

Lurasidone monotherapy for the treatment of bipolar depression significantly improved functioning and reduced indirect costs vs. placebo at week 6. Significant improvements in functioning and productivity were sustained for 6 months for both LUR-LUR and PBO-LUR.

Economic burden of attention-deficit/hyperactivity disorder among children and adolescents in the United States: a societal perspective

OBJECTIVE

To provide a comprehensive evaluation of the economic burden associated with attention-deficit/hyperactivity disorder (ADHD) among children and adolescents from a US societal perspective.

MATERIALS AND METHODS

Direct healthcare costs of children (5-11 years) and adolescents (12-17 years) with ADHD were obtained using claims data from the IBM MarketScan Research Databases (01/01/2017-12/31/2018). Direct non-healthcare and indirect costs were estimated based on literature and government publications. Each cost component was estimated using a prevalence-based approach, with per-patient costs extrapolated to the national level.

RESULTS

The total annual societal excess costs associated with ADHD were estimated at $19.4 billion among children ($6,799 per child) and $13.8 billion among adolescents ($8,349 per adolescent). Education costs contributed to approximately half of the total excess costs in both populations ($11.6 billion [59.9%] in children; $6.7 billion [48.8%] in adolescents). Other major contributors to the overall burden were direct healthcare costs ($5.0 billion [25.9%] in children; $4.0 billion [29.0%] in adolescents) and caregiving costs ($2.7 billion [14.1%] in children; $1.6 billion [11.5%] in adolescents).

LIMITATIONS

Cost estimates were calculated based on available literature and/or governmental publications due to the absence of a single data source for all costs associated with ADHD. Thus, the quality of cost estimates is limited by the accuracy of available data as well as the study populations and methodologies used by different studies.

CONCLUSION

ADHD in children and adolescents is associated with a substantial economic burden that is largely driven by education costs, followed by direct healthcare costs and caregiver costs. Improved intervention strategies and policies may reduce the clinical and economic burden of ADHD in these populations.

Place of care and costs associated with acute episodes and remission in bipolar I disorder

AIMS

To our knowledge, literature describing the place of care and associated costs during acute bipolar I disorder (BP-I) episodes is limited. We conducted a claims-based retrospective study to address this gap.

MATERIALS AND METHODS

Adults with BP-I were identified via IBM MarketScan Commercial and Medicare Supplemental databases. The acute episode index date was defined by ≥1 inpatient BP-I claim(s) or ≥1 outpatient or ≥3 outpatient BP-I claims (depending on visit type) in a 2-week (manic/mixed) or 4-week (depressive) period. Likely acute episodes were defined as 3- and 6-week periods for manic/mixed and depressive episodes, respectively; total mental health-related medical costs (health plan + patient) were collected during these intervals and stratified by setting (inpatient versus outpatient). Initial and subsequent episodes were captured; data were reported in subgroups without and with clozapine use, a proxy for disease severity. The remission index date was the earliest outpatient claim with a bipolar remission diagnosis with no acute episode or treatment. Remission costs were collected over a 3-month period. All results were analyzed descriptively.

RESULTS

A total of 41,516 patients with 130,221 acute manic/mixed episodes and 47,763 patients with 149,207 acute depressive episodes met the study criteria. Over 84% of acute episodes were treated in outpatient settings. Mental health-related medical costs for manic/mixed episodes were $15,444 for inpatient and $1,577 for outpatient settings; inpatient and outpatient costs for depressive episodes were $17,376 and $2,154, respectively. Health plans covered approximately 78% of medical costs for both episode types with and without prior clozapine use. A total of 8,143 patients met remission criteria; the total 3-month outpatient costs were $1,225.

CONCLUSIONS

Most BP-I acute manic/mixed or depressive episodes were treated in the outpatient setting. Episodes with inpatient care were 8-10 times more costly than outpatient-only episodes. Health plans covered most medical costs, but additional patient-incurred out-of-pocket costs remained.

Increased Asymmetric Perfusion of the Cerebral Cortices and Thalamus Indicates Individuals at Risk for Bipolar Disorder: A Family Cohort Single Photon Emission Computed Tomography Neuroimaging Study

Bipolar disorder is a significant mental illness affecting over 4 million people in North America and approximately 46 million worldwide. While the onset of bipolar disorder is typically in late adolescence and early adulthood, the correct diagnosis can be delayed for several years. This delay can result in inappropriate pharmaceutical interventions, loss of career or productivity, suicide, family hardship, and unnecessary expense. Moreover, prolonged untreated or inappropriately treated bipolar disorder may cause damage to the brain. Early diagnosis is a critical need to circumvent the damage, suffering, and expense caused by the current delay. Brain perfusion single photon emission computed tomography (SPECT) neuroimaging reveals visual correlates of brain function. Herein, a family cohort all with bipolar disorder is described and their symptoms correlated with findings on the individual SPECT brain scans. The family consisted of two parents and three children (one female). The scans were interpreted by a panel of experts. Then a post hoc region-of-interest (ROI) analysis was conducted on SPECT data normalized to the cerebellum maximum with comparison to similarly normalized data from a normative sample. These findings support two distinct patterns of SPECT perfusion scan changes that can be found in individuals with bipolar disorder. In addition, these findings indicate that SPECT scan findings may be predictive of individual risk for progressing to symptomatic bipolar disorder. While preliminary, the findings in this cohort support the need for larger, diverse cohort studies of bipolar and control subjects to assess the predictive value of these particular SPECT perfusion findings in bipolar disorder.

Characterisation of age and polarity at onset in bipolar disorder

BACKGROUND

Studying phenotypic and genetic characteristics of age at onset (AAO) and polarity at onset (PAO) in bipolar disorder can provide new insights into disease pathology and facilitate the development of screening tools.

AIMS

To examine the genetic architecture of AAO and PAO and their association with bipolar disorder disease characteristics.

METHOD

Genome-wide association studies (GWASs) and polygenic score (PGS) analyses of AAO (n = 12 977) and PAO (n = 6773) were conducted in patients with bipolar disorder from 34 cohorts and a replication sample (n = 2237). The association of onset with disease characteristics was investigated in two of these cohorts.

RESULTS

Earlier AAO was associated with a higher probability of psychotic symptoms, suicidality, lower educational attainment, not living together and fewer episodes. Depressive onset correlated with suicidality and manic onset correlated with delusions and manic episodes. Systematic differences in AAO between cohorts and continents of origin were observed. This was also reflected in single-nucleotide variant-based heritability estimates, with higher heritabilities for stricter onset definitions. Increased PGS for autism spectrum disorder (β = -0.34 years, s.e. = 0.08), major depression (β = -0.34 years, s.e. = 0.08), schizophrenia (β = -0.39 years, s.e. = 0.08), and educational attainment (β = -0.31 years, s.e. = 0.08) were associated with an earlier AAO. The AAO GWAS identified one significant locus, but this finding did not replicate. Neither GWAS nor PGS analyses yielded significant associations with PAO.

CONCLUSIONS

AAO and PAO are associated with indicators of bipolar disorder severity. Individuals with an earlier onset show an increased polygenic liability for a broad spectrum of psychiatric traits. Systematic differences in AAO across cohorts, continents and phenotype definitions introduce significant heterogeneity, affecting analyses.

Economic burden of attention-deficit/hyperactivity disorder among adults in the United States: a societal perspective

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with substantial clinical burden as individuals transition to adulthood, including higher rates of comorbidities, mortality, incarceration, and psychiatric hospitalizations than in individuals without ADHD. These higher rates likely contribute to substantial economic burden as well. OBJECTIVE: To provide a comprehensive evaluation of the economic burden associated with ADHD in the US adult population. METHODS: Direct health care costs were obtained by using claims data from the IBM MarketScan Research Databases (January 1, 2017, through December 31, 2018). Direct non-health care costs and indirect costs were estimated on the basis of the literature and government publications. Excess costs incurred by adults with ADHD during 2018 were evaluated from a societal perspective; per-patient costs were extrapolated to the national level. RESULTS: An estimated 8.7 million adults live with ADHD in the United States, resulting in a total societal excess cost attributable to ADHD of $122.8 billion ($14,092 per adult). Excess costs of unemployment ($66.8 billion; 54.4%) comprised the largest proportion of the total, followed by productivity loss ($28.8 billion; 23.4%) and health care services ($14.3 billion; 11.6%). CONCLUSIONS: ADHD in adults is associated with substantial economic burden. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. (Otsuka). The study sponsor contributed to and approved the study design, participated in the interpretation of data, and reviewed and approved the manuscript. Schein is an employee of Otsuka. Gagnon-Sanschagrin, Davidson, Kinkead, Cloutier, Guérin, and Lefebvre are employees of Analysis Group, Inc., a consulting company that provided paid consulting services to Otsuka to develop and conduct this study and write the manuscript. Adler has received research support from Shire/Takeda, Sunovion, and Otsuka; consulting fees from Bracket, Shire/Takeda, Sunovion, Otsuka, the State University of New York (SUNY), the National Football League (NFL), and Major League Baseball (MLB); and royalty payments (as inventor) from New York University (NYU) for license of adult ADHD scales and training materials. Childress has received research support from Allergan, Takeda/Shire, Emalex, Akili, Ironshore, Arbor, Aevi Genomic Medicine, Neos Therapeutics, Otsuka, Pfizer, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, and the US Food and Drug Administration; was on the advisory board of Takeda/Shire, Akili, Arbor, Cingulate, Ironshore, Neos Therapeutics, Otsuka, Pfizer, Purdue, Adlon, Rhodes, Sunovion, Tris, Supernus, and Corium; received consulting fees from Arbor, Ironshore, Neos Therapeutics, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, Corium, Jazz, and Tulex Pharma; received speaker fees from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Tris, and Supernus; and received writing support from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Purdue, Rhodes, Sunovion, and Tris. Part of the material in this study was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2021 Virtual Meeting; May 17-20, 2021.

Comparison of thyroid function in different emotional states of drug-naïve patients with bipolar disorder

BACKGROUND

Previous studies have shown that bipolar disorder is closely related to thyroid dysfunction. Psychiatric drugs have a large or small effect on thyroid function, and thyroid hormone levels can also affect the effect of drug treatment. Therefore, the purpose of this study is assessment the thyroid function of drug-naive bipolar disorder across different mood states, with the expectation of providing support for treatment options.

METHODS

The present study is a cross-sectional study. Patients diagnosed with bipolar disorder according to the International Classification of Diseases diagnostic Criteria, Edition 10 (ICD 10) and who had never received medication were included in the study. The Montgomery Depression Scale (MADRS) was used to assess depressive symptoms and the Young Mania Rating Scale (YMRS) for manic symptoms. Thyroid function indicators include thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), total triiodothyronine (TT3), free thyroxine (FT4), and total thyroxine (TT4). Levels of TSH, TT4, FT4, TT3, and FT3 were measured within 48 h of hospitalization, between 06:00 and 08:00.

RESULTS

The data analysis finally covered the data of 291 subjects (136 in a bipolar manic group, 128 in a bipolar depressive group, and 27 in a bipolar mixed group), including 140 males and 151 females, with an average age of 27.38 ± 8.01. There was no significant difference in age, sex, marital status, work status, family history, and course of illness among the manic group, depressive group, and mixed group. The level of FT3, the rate of thyroid hormone increased secretion, and the total abnormality rate of thyroid hormone secretion in the manic group were significantly higher than those in the depressive group.

CONCLUSION

These findings indicate that thyroid functions were significantly different between depressive and manic episodes in BD patients. In clinical practice, it is necessary to take into account the differences in thyroid hormone levels in patients with BD across different emotional states in choosing drug.

Impact of treatment-related discussions on healthcare resource use and costs among patients with severe mental illness

OBJECTIVE

Serious mental illnesses (SMIs), including schizophrenia, bipolar disorder, and major depressive disorder (MDD), are often treated with antipsychotic medications. Unfortunately, medication non-adherence is widespread and is associated with serious adverse outcomes. However, little real-world data are available describing adherence, compliance, or other medication-taking-related discussions between providers and patients. This study described these communications in ambulatory care.

METHODS

Commercially insured patients having acute (emergency or inpatient) behavioral health (BH) events were included by specific criteria: age 18-65 years; diagnoses of schizophrenia, bipolar disorder, or MDD; continuous health insurance coverage 6 months before to 12 months after the first claim (index) date during 01/01/2014‒12/31/2015; and prescribed antipsychotic medication. Medical charts were abstracted for ambulatory visits with a BH diagnosis through 12 months after the acute event, describing any treatment compliance discussions that occurred. BH-related healthcare utilization and costs were measured via insurance claims. Results were analyzed by observation of an antipsychotic medication taking-related (i.e. compliance or adherence) discussion at the initial abstracted visit.

RESULTS

Ninety patients were included: 62% female, mean age 41 years. Only 58% had antipsychotic compliance discussions during the first abstracted ambulatory visit. A total of 680 BH-related visits were abstracted for the 90 patients. Providers frequently discussed any psychotropic medication use (97% of all visits abstracted); however, discussion of compliance with BH talk therapies was less common (49% of visits among patients with a first visit antipsychotic discussion and 23% without, p < .001). Follow-up BH-related healthcare utilization and costs were not significantly different by cohort. Patients with ≥2 compliance discussions had a significantly lower risk of follow-up acute events, which are the costliest components of healthcare for SMI (p = .023).

CONCLUSION

Increasing the frequency of antipsychotic treatment-related adherence/compliance discussions may represent an opportunity to improve the quality of care for these vulnerable patients and reduce the overall economic burden associated with the treatment of SMI diagnosis.

Exploring factors associated with personal recovery in bipolar disorder

BACKGROUND

Personal recovery is increasingly recognized as important outcome for people with bipolar disorder (BD), but research addressing associated factors of personal recovery in this group remains scarce. This study aimed to explore the association of sociodemographic variables, social participation, psychopathology, and positive emotion regulation with personal recovery in BD.

METHODS

Baseline data from a randomized controlled trial and survey data were combined (N = 209) and split into a training (n = 149) and test sample (n = 60). Block-wise regression analyses and model training were used to determine the most relevant predictors. The final parsimonious model was cross-validated in the test sample.

RESULTS

In the final parsimonious model, satisfaction with social roles (β = .442, p < .001), anxiety symptoms (β = -.328, p < .001), manic symptoms (β = .276, p < .001), and emotion-focused positive rumination (β = .258, p < .001) were independently associated with personal recovery. The model explained 57.3% variance in personal recovery (adjusted R²  = .561) and performed well in predicting personal recovery in the independent test sample (adjusted R²  = .491).

CONCLUSIONS

Our findings suggest that especially social participation, anxiety and positive rumination might be relevant treatment targets when aiming to improve personal recovery.

PRACTITIONER POINTS

Personal recovery is considered an increasingly important outcome for people with chronic mental health conditions, including bipolar disorder. We found that anxiety and manic symptoms as well as positive rumination and social participation were independently associated with personal recovery in bipolar disorder. Therefore, these outcomes might be relevant treatment targets when aiming to improve personal recovery in bipolar disorder. Possible interventions to improve these outcomes are discussed, including supported employment and vocational rehabilitation for social participation and exercising with savoring strategies to increase positive rumination.

A Systematic Review of the Clinical Use of Gabapentin and Pregabalin in Bipolar Disorder

Despite its prevalence and disease burden, several chasms still exist with regard to the pharmacotherapy of bipolar disorder (BD). Polypharmacy is commonly encountered as a significant proportion of patients remain symptomatic, and the management of the depressive phase of the illness is a particular challenge. Gabapentin and pregabalin have often been prescribed off-label in spite of a paucity of evidence and clinical practice guidelines to support its use. This systematic review aimed to synthesize the available human clinical trials and inform evidence-based pharmacological approaches to BD management. A total of six randomized, controlled trials (RCTs) and 13 open-label trials involving the use of gabapentin and pregabalin in BD patients were reviewed. Overall, the studies show that gabapentin and its related drug pregabalin do not have significant clinical efficacy as either monotherapy or adjunctive therapy for BD. Gabapentin and pregabalin are probably ineffective for acute mania based on the findings of RCT, with only small open-label trials to support its potential adjunctive role. However, its effects on the long-term outcomes of BD remain to be elucidated. The evidence base was significantly limited by the generally small sample sizes and the trials also had heterogeneous designs and generally high risk of bias.