Gender and mental health service use in bipolar disorder: national cohort study

Labor market marginalization in individuals with bipolar disorder: a Swedish nationwide register-based sibling comparison study

BACKGROUND

There is a lack of large-scale studies exploring labor market marginalization (LMM) among individuals diagnosed with bipolar disorder (BD). We aimed to investigate the association of BD with subsequent LMM in Sweden, and the effect of sex on LMM in BD.

METHODS

Individuals aged 19-60 years living in Sweden with a first-time BD diagnosis between 2007 and 2016 (n = 25 231) were followed from the date of diagnosis for a maximum of 14 years. Risk of disability pension (DP), long-term sickness absence (SA) (>90 days), and long-term unemployment (>180 days) was compared to a matched comparison group from the general population, matched 1:5 on sex and birth year (n = 126 155), and unaffected full siblings (n = 24 098), using sex-stratified Cox regression analysis, yielding hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

After adjusting for socioeconomic factors, baseline labor market status, and comorbid disorders, individuals with BD had a significantly higher risk of DP compared to the general population (HR = 16.67, 95% CI 15.33-18.13) and their unaffected siblings (HR = 5.54, 95% CI 4.96-6.18). Individuals with BD were also more likely to experience long-term SA compared to the general population (HR = 3.19, 95% CI 3.09-3.30) and their unaffected siblings (HR = 2.83, 95% CI 2.70-2.97). Moreover, individuals diagnosed with BD had an elevated risk of long-term unemployment relative to both comparison groups (HR range: 1.75-1.78). Men with BD had a higher relative risk of SA and unemployment than women. No difference was found in DP.

CONCLUSIONS

Individuals with BD face elevated risks of LMM compared to both the general population and unaffected siblings.

Predictors of Engagement in Multiple Modalities of Digital Mental Health Treatments: Longitudinal Study

BACKGROUND

Technology-enhanced mental health platforms may serve as a pathway to accessible and scalable mental health care; specifically, those that leverage stepped care models have the potential to address many barriers to patient care, including low mental health literacy, mental health provider shortages, perceived acceptability of care, and equitable access to evidence-based treatment. Driving meaningful engagement in care through these platforms remains a challenge.

OBJECTIVE

This study aimed to examine predictors of engagement in self-directed digital mental health services offered as part of an employer-based mental health benefit that uses a technology-enabled care platform.

METHODS

Using a prospective, longitudinal design, we examined usage data from employees who had access to an employer-sponsored mental health care benefit. Participants had access to a digital library of mental health resources, which they could use at any time, including daily exercises, interactive programs, podcasts, and mindfulness exercises. Coaching and teletherapy were also available to. The outcome was engagement with the self-directed digital mental health resources, measured by the number of interactions. Poisson regression models included sociodemographic characteristics, patient activation, mental health literacy, well-being, PHQ-9 and GAD-7 scores at baseline, primary concern for engaging in treatment, and the use of coaching or teletherapy sessions.

RESULTS

In total 950 individuals enrolled in the study, with 38% using any self-directed digital mental health resources. Approximately 44% of the sample did not use the app during the study period. Those using both self-directed digital and 1:1 modalities made up about one-quarter of the sample (235/950, 24.7%). Those using only coaching or therapy (170/950, 17.9%) and those using only self-directed digital mental health resources (126/950, 13.3%) make up the rest. At baseline, these groups statistically significantly differed on age, PHQ-9, GAD-7, MHLS, and primary concern. Receipt of coaching and teletherapy was associated with the number of self-directed digital mental health resources interactions in adjusted Poisson regression modeling. Use of any coach visit was associated with 82% (rate ratio [RR] 1.82, 95% CI 1.63-2.03) more self-directed digital mental health resource interactions while use of any teletherapy session was associated with 80% (RR 1.80, 95% CI 1.55-2.07) more digital mental health resources interactions (both P<.001). Each additional year of age was associated with increased digital mental health resources interactions (RR 1.04, 95% CI (1.03-1.05), and women had 23% more self-directed digital resources interactions than men (RR 1.23, 95% CI 1.09-1.39).

CONCLUSIONS

Our key finding was that the use of coaching or teletherapy was associated with increased self-directed digital mental health resource use. Higher self-directed digital resource engagement among those receiving coaching or therapy may be a result of provider encouragement. On the other hand, when a participant engages with 1 modality in the platform, they may be more likely to begin engaging with others, becoming "super users" of all resources.

Global, regional and national burdens of bipolar disorders in adolescents and young adults: a trend analysis from 1990 to 2019

Background

Bipolar disorder is identified as a cause of severe damage to the physical, psychological and social functioning of adolescents and young adults.

Aims

The aim of this study is to ascertain the trends in the burden of bipolar disorder among individuals aged 10-24 years at global, regional and national levels from 1990 to 2019.

Methods

The data analysed in this study were from the Global Burden of Diseases 2019. The numbers, rates per 100 000 population, average annual percentage changes (AAPCs) of incidence, prevalence and years lived with disability (YLDs) of bipolar disorder are reported at the global, regional and national levels among individuals aged 10-24 years. Global trends by age, sex and Social Development Index (SDI) were further analysed.

Results

Globally, the incidence of bipolar disorder among adolescents and young adults increased from 79.21 per 100 000 population (95% uncertainty interval (UI): 58.13 to 105.15) in 1990 to 84.97 per 100 000 population (95% UI: 61.73 to 113.46) in 2019, AAPC 0.24 (95% confidence interval (CI): 0.22 to 0.26). In the past three decades, there has been an increase in incidence, prevalence and YLDs in both males and females. The largest increase in incidence between 1990 and 2019 was observed in those aged 20-24 years old (from 51.76 per 100 000 population (95% UI: 26.81 to 87.20) in 1990 to 58.37 per 100 000 population (95% UI: 30.39 to 98.55) in 2019; AAPC 0.42 (95% CI: 0.38 to 0.47)). By the SDI quintile, the largest increase in incidence was observed in the middle SDI; however, the high SDI countries had the highest incidence. Regionally, the largest increase in incidence was observed in southern Latin America. At the national level, the most pronounced increase in the incidence was in Greenland.

Conclusions

The global increase in incidence among adolescents and young adults between 1990 and 2019 indicates that strategies to improve their mental health still need to be emphasised.

Sex Differences in Brain Disorders

A remarkable feature of the brain is its sexual dimorphism. Sexual dimorphism in brain structure and function is associated with clinical implications documented previously in healthy individuals but also in those who suffer from various brain disorders. Sex-based differences concerning some features such as the risk, prevalence, age of onset, and symptomatology have been confirmed in a range of neurological and neuropsychiatric diseases. The mechanisms responsible for the establishment of sex-based differences between men and women are not fully understood. The present paper provides up-to-date data on sex-related dissimilarities observed in brain disorders and highlights the most relevant features that differ between males and females. The topic is very important as the recognition of disparities between the sexes might allow for the identification of therapeutic targets and pharmacological approaches for intractable neurological and neuropsychiatric disorders.

Culturally competent, safe and equitable clinical care for Ma¯ori with bipolar disorder in New Zealand: The expert critique of Ma¯ori patients and Wha¯nau

OBJECTIVE

Research designed to increase knowledge about Māori with bipolar disorder is required to understand how health services support wellbeing and respond to identified levels of community need. This paper synthesises the expert critique of Māori patients with bipolar disorder and their whānau regarding the nuances of cultural competence and safety in clinical encounters with the health system.

METHODS

A qualitative Kaupapa Māori Research methodology was used. A total of 24 semi-structured interviews were completed with Māori patients with bipolar disorder and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three themes were evident from participants' critique of clinical components of the health system. Theme 1 established that the efficacy of clinical care for bipolar disorder was dependent on Māori patients and whānau having clear pathways through care, and being able to access timely, consistent care from clinically and culturally competent staff. Theme 2 identified the influence of clinical culture in bipolar disorder services, embedded into care settings, expressed by staff, affecting the safety of clinical care for Māori. Theme 3 focused on the need for bipolar disorder services to prioritise clinical work with whānau, equip staff with skills to facilitate engagement and tailor care with resources to enhance whānau as well as patient wellbeing.

CONCLUSION

The standard of clinical care for Māori with bipolar disorder in New Zealand does not align with practice guidelines, Māori models of health or clinical frameworks designed to inform treatment and address systemic barriers to equity. Research also needs to explore the role of structural and organisational features of the health system on Māori patient and whānau experiences of care.

Preventive Medication Patterns in Bipolar Disorder and Their Relationship With Comorbid Substance Use Disorders in a Cross-National Observational Study

OBJECTIVE

The potential role of sub-optimal pharmacological treatment in the poorer outcomes observed in bipolar disorder (BD) with vs. without comorbid substance use disorders (SUDs) is not known. Thus, we investigated whether patients with BD and comorbid SUD had different medication regimens than those with BD alone, in samples from France and Norway, focusing on compliance to international guidelines.

METHODS

Seven hundred and seventy patients from France and Norway with reliably ascertained BD I or II (68% BD-I) were included. Medication information was obtained from patients and hospital records, and preventive treatment was categorized according to compliance to guidelines. We used Bayesian and regression analyses to investigate associations between SUD comorbidity and medication. In the Norwegian subsample, we also investigated association with lack of medication.

RESULTS

Comorbid SUDs were as follows: current tobacco smoking, 26%, alcohol use disorder (AUD), 16%; cannabis use disorder (CUD), 10%; other SUDs, 5%. Compliance to guidelines for preventive medication was lacking in 8%, partial in 44%, and complete in 48% of the sample. Compliance to guidelines was not different in BD with and without SUD comorbidity, as was supported by Bayesian analyses (highest Bayes Factor = 0.16). Cross national differences in treatment regimens led us to conduct country-specific adjusted regression analyses, showing that (1) CUD was associated with increased antipsychotics use in France (OR = 2.4, 95% CI = 1.4-3.9, p = 0.001), (2) current tobacco smoking was associated with increased anti-epileptics use in Norway (OR = 4.4, 95% CI = 1.9-11, p < 0.001), and (3) AUD was associated with decreased likelihood of being medicated in Norway (OR = 1.2, 95% CI = 1.04-1.3, p = 0.038).

CONCLUSION

SUD comorbidity in BD was overall not associated with different pharmacological treatment in our sample, and not related to the level of compliance to guidelines. We found country-specific associations between comorbid SUDs and specific medications that warrant further studies.

Sex differences in neurocognitive and psychosocial functioning in bipolar disorder

BACKGROUND

Sex differences influence the clinical characteristics and course of illness of bipolar disorder (BD).

OBJECTIVE

Therefore, the aim of the present study was to examine the role of sex differences in neurocognitive performance and psychosocial functioning in a large sample of euthymic patients suffering from BD.

METHODS

The sample included 462 individuals, 347 patients with BD (148 males and 199 females) and 115 healthy controls (HC) (45 males and 70 females). Performance on a comprehensive neuropsychological battery assessing six cognitive domains and psychosocial functioning was compared between groups using linear mixed models, with sex and group as main effects, group by sex interactions and center as a random effect.

RESULTS

Males performed better than females in working memory (p < 0.001), whereas females outperformed males in the verbal learning (p = 0.03) and memory recognition (p = 0.03) tasks. No significant group by sex interactions were detected in cognitive performance. There were no overall sex differences or group by sex interactions in psychosocial functioning.

LIMITATIONS

Lack of assessment of visuo-spatial working memory.

CONCLUSIONS

There were no overall sex differences in neurocognition and psychosocial functioning. However, small sex differences in some measures of working memory and verbal memory were found. Individual differences of each patient, including sex perspective, should be considered in order to perform a tailored intervention plan adjusted to specific needs in the context of personalized treatment.

Care for Women with Delusional Disorder: Towards a Specialized Approach

Delusional disorder is a difficult-to-treat clinical condition with health needs that are often undertreated. Although individuals with delusional disorder may be high functioning in daily life, they suffer from serious health complaints that may be sex-specific. The main aim of this narrative review is to address these sex-specific health needs and to find ways of integrating their management into service programs. Age is an important issue. Delusional disorder most often first occurs in middle to late adult life, a time that corresponds to menopause in women, and menopausal age correlates with increased development of both somatic and psychological health problems in women. It is associated with a rise in the prevalence of depression and a worsening of prior psychotic symptoms. Importantly, women with delusional disorder show low compliance rates with both psychiatric treatment and with medical/surgical referrals. Intervention at the patient, provider, and systems levels are needed to address these ongoing problems.