Use of treatment services and pharmacotherapy for bipolar disorder in a general population-based mental health survey

A systematic review and meta-analysis of delayed help-seeking, delayed diagnosis and duration of untreated illness in bipolar disorders

OBJECTIVES

To examine the time delay between the age at onset of symptoms or episodes of bipolar disorders (BD) and the age at diagnosis of and/or receipt of clinical practice guideline recommended interventions for BD.

METHODS

Systematic search of five databases to identify publications from January 2000 to July 2022 that reported one or more of the following reliable and valid estimates of latency: delay in help seeking (DHS), delay in diagnosis (DD) and duration of untreated BD (DUB). Eligible studies were included in random effects meta-analyses and multivariate meta-regression was used to assess factors associated with each latency construct.

RESULTS

Screening of 1074 publications identified 59 eligible studies (reported in 66 publications) of >40,000 individuals that estimated DHS (8 studies), DD (20 studies) and/or DUB (45 studies). The median DHS, DD and DUB were 3.5 (IQR: 2.8, 8.48), 6.7 (IQR: 5.6, 8.9) and 5.9 years (IQR: 1.1, 8.2), respectively. Key factors associated with shorter DD included older age and residing outside North America; shorter DUB was associated with psychotic or manic onset and access to early intervention services.

CONCLUSIONS

Greater consensus on definitions of latency constructs and better-quality targeted research is required regarding DHS, DD and DUB. This review suggests that, while the peak age at onset of BD is 15-25, diagnosis and guideline recommended interventions (e.g., mood stabilizers) are likely to be delayed until age 25-35 years except for a minority of individuals with access to early intervention services.

Bipolar Disorder Related Hospitalizations - a Descriptive Nationwide Study Using a Big Data Approach

Bipolar Disorder (BD) is a mental disorder which frequently requires long hospitalizations and need for acute psychiatric care. The aim of this study was to describe a nationwide perspective of BD related hospitalizations and to use a BigData based approach in mental health research. We performed a retrospective observational study using a nationwide hospitalization database containing all hospitalizations registered in Portuguese public hospitals from 2008-2015. Hospitalizations with a primary diagnosis of BD were selected based on International Classification of Diseases version 9, Clinical Modification (ICD-9-CM) codes of diagnosis 296.xx (excluding 296.2x; 296.3x and 296.9x). From 20,807 hospitalizations belonging to 13,300 patients, around 33.4% occurred in male patients with a median length of stay of 16.0 days and a mean age of 47.9 years. The most common hospitalization diagnosis in BD has the code 296.4x (manic episode) representing 34.3% of all hospitalizations, followed by the code 296.5x (depressed episode) with 21.4%. The mean estimated hospitalization charge was 3,508.5€ per episode, with a total charge of 73M€ in the 8-year period of this study.This is a nationwide study giving a broad perspective of the BD hospitalization panorama at a national level. We found important differences in hospitalization characteristics by sex, age and primary diagnosis.

A prospective longitudinal study searching for predictors of response to group psychoeducation in bipolar disorder

BACKGROUND

The efficacy of adjunctive group psychoeducation in bipolar disorder has been proven although treatment response differ among individuals. The aim of this study was to characterize responders and non-responders to group psychoeducation in order to identify baseline variables that could predict treatment response.

METHODS

The sample was composed of 103 medicated euthymic patients with bipolar disorder referred to 21 sessions of group psychoeducation (6 months). Sociodemographic and clinical variables, temperament, circadian rhythms, BDNF, cognitive and psychosocial functioning were collected. At the 18-month endpoint, the patients were split in two groups on the basis of having suffered any recurrence. Significant group differences were included in a logistic regression analysis.

RESULTS

Ninety patients out of 103 engaged in group psychoeducation, 47 of whom (52.2%) responded to psychoeducation and 43 (47.8%) did not. Recurrences occurred more often in the follow-up, the most common being depression. Responders and non-responders differed in gender, age at diagnosis, latency of diagnosis, temperament, attention composite score and BDNF. Lower age at diagnosis of bipolar disorder, lower cyclothimic temperament scores and being male -which was associated with bipolar type I and a trend to more previous manic episodes- were significantly related to a better response to psychoeducation in the regression analysis.

LIMITATIONS

No control group.

CONCLUSIONS

This study identifies age at diagnosis as a significant modifiable risk factor of treatment response, highlighting the need for early identification of bipolar disorder. Existing programs should be adjusted to the characteristics of specific subpopulations in the framework of a personalized approach.

Chronic Periodontitis Is Associated with the Risk of Bipolar Disorder: A Population-Based Cohort Study

Bipolar disorder (BD) is a psychiatric mood disturbance manifested by manic, hypomanic, or major depressive periods. Chronic inflammation was evidenced as an important etiologic factor of BD. Chronic periodontitis (CP) is an inflammatory disease triggered by bacterial products, leading to the destruction of periodontium. The relationship between BD and CP is of interest to investigate. Therefore, a nationwide population-based cohort study was used to investigate the risk of BD and CP exposure from 2001 to 2012. We identified 61,608 patients with CP from the Taiwanese National Health Insurance Research Database (NHIRD). The 123,216 controls were randomly captured and matched by age, sex, index year, and co-morbidities. The association between CP exposure and BD risk was examined by Cox proportional hazards regression models. In this study, 61,608 CP patients and 123,216 controls were followed up for 7.45 and 7.36 years, respectively. In total, 138 BD patients were identified in the CP cohort and 187 BD cases were found in the non-CP cohort. The incidence rate of BD was significantly higher in the CP cohort than in the non-CP cohort (adjusted HR: 1.46, 95% CI: 1.17–1.81) according to the multivariate Cox regression analysis. Females had a 1.47-fold increased risk (95% CI: 1.16–1.86) for BD compared to males. Taken together, CP may be associated with an increased risk of subsequent BD in Taiwan.

Attitudes towards psychopharmacology and psychotherapy in psychiatric patients with and without migration background

BACKGROUND

Sociodemographic factors, attitude towards treatment and acculturation may be important factors influencing the decision of immigrants to seek and maintain psychiatric treatment. A better understanding of these factors may significantly improve treatment adherence and outcome in these patients. Therefore, we investigated factors associated the attitude towards psychotherapy and medication in a sample of psychiatric outpatients with and without migration background.

METHODS

N = 381 patients in a psychiatric outpatient unit offering specialized treatment for migrants were included in this study. Attitude towards psychotherapy was assessed using the Questionnaire on Attitudes Toward Psychotherapeutic Treatment, attitude towards medication with the Drug Attitude Inventory-10. Acculturation, symptom load and sociodemographic variables were assessed in a general questionnaire. Statistical analyses included analyses of covariance and hierarchical regression.

RESULTS

Patients of Turkish and Eastern European origin reported a significantly more positive attitude towards medication than patients without migration background. When controlling for sociodemographic and clinical variables, we did not observe any significant differences in attitude towards psychotherapy. Acculturation neither influenced the attitude towards psychotherapy nor towards medication.

CONCLUSION

Our study indicates that sociodemographic and clinical factors may be more relevant for patients´ attitudes towards treatment than acculturation. Considering these factors in psychiatric treatment of patients with migration background may improve treatment outcome and adherence.

Systemic autoimmune diseases are associated with an increased risk of bipolar disorder: A nationwide population-based cohort study

BACKGROUND

Studies suggested autoimmunity plays a role in the etiology of bipolar disorder (BD). This study aimed to investigate the association between systemic autoimmune diseases (SADs) and the subsequent development of BD, and examine the potential risk factors for developing BD.

METHODS

Patients with SADs were identified in the Taiwan National Health Insurance Program (NHIP). A comparison cohort was created by matching patients without SADs with age. The SADs cohort consisted of 65,498 while the comparison cohort consisted of 261,992 patients. The incidence of BD was evaluated in both cohorts.

RESULTS

The major finding was the discovery of a higher incidence of subsequent BD among patients with SADs (adjusted hazard ratio: 1.98). Specifically, the risk of BD was observed to be significant increase in systemic lupus erythematosus, rheumatoid arthritis, autoimmune vasculitis, Sicca syndrome and Crohn's disease. Furthermore, our study revealed some potential risk factors for developing BD including female, younger age and patients who lived in eastern Taiwan. Also, some comorbidities including dyslipidemia, chronic obstructive pulmonary disease, diabetes mellitus, asthma, cerebrovascular disease, alcohol used disorder, liver cirrhosis, and malignancies were potential risk factors for incident BD.

LIMITATIONS

The diagnosis of SADs was based on the catastrophic illness certificate defined by Taiwanese NHIP. Thus, not every form of SADs was explored for subsequent developing BD.

CONCLUSION

This study confirms that SADs are associated with higher incidence of BD, suggesting that abnormal autoimmune process is associated with increased expression of psychiatric disturbances.

Influence of gender on inpatient treatment for bipolar disorder: An analysis of 60,607 hospitalisations

BACKGROUND

The influence of gender on inpatient treatment patterns in bipolar patients is unclear. The aim of this study is to examine whether differences in length of stay and frequency of inpatient episodes, according to ICD-10 bipolar disorder (BD)-subgroups, exist between men and women.

METHODS

All episodes of a manic (F31.0-2), depressive (F31.3-5) or mixed (F31.6) subtype of BD during an inpatient stay in an Austrian hospital in the period of 2001-2014 were included in this study. Data on episodes was provided by the national statistics agency. Weekly admission rates per 100,000 people were calculated by directly age-standardized rates.

RESULTS

The database comprised 60,607 admissions (35.8% men). The number of inpatient episodes was significantly higher (p < 0.001) in women in all BD subgroups. Average length of stay in manic (p < 0.001) and depressive (p < 0.001) episodes was shorter in women compared to men. No difference could be found for mixed episodes.

LIMITATIONS

Only aggregated patient data and no single case histories were available for this study.

CONCLUSIONS

The current study reveals relevant gender differences regarding inpatient treatment patterns, as women were overrepresented in all BD-subgroups. Despite equal life time prevalence, severe mood episodes lead more often to hospitalisations in women. There is a high necessity to further research the underlying causes of these findings.

Self-poisoning suicide deaths in people with bipolar disorder: characterizing a subgroup and identifying treatment patterns

OBJECTIVE

To characterize self-poisoning suicide deaths in BD compared to other suicide decedents.

METHODS

Extracted coroner data from all suicide deaths (n = 3319) in Toronto, Canada from 1998 to 2012. Analyses of demographics, clinical history, recent stressors, and suicide details were conducted in 5 subgroups of suicide decedents: BD self-poisoning, BD other methods, non-BD self-poisoning, non-BD other methods, and unipolar depression self-poisoning. Toxicology results for lethal and present substances were also compared between BD and non-BD self-poisoning subgroups as well as between BD and unipolar depression self-poisoning subgroups.

RESULTS

Among BD suicide decedents, self-poisoning was significantly associated with female sex, past suicide attempts, and comorbid substance abuse. In both the BD and non-BD self-poisoning groups, opioids were the most common class of lethal medication. For both groups, benzodiazepines and antidepressants were the most common medications present at time of death, and in 23% of the BD group, an antidepressant was present without a mood stabilizer or antipsychotic. Only 31% of the BD group had any mood stabilizer present, with carbamazepine being most common. No antidepressant, mood stabilizer, or antipsychotic was present in 15.5% of the BD group. Relative to unipolar depression self-poisoning group, the BD self-poisoning group evidenced higher proportion of previous suicide attempt(s) and psychiatry/ER visits in the previous week.

CONCLUSION

People with BD who die by suicide via self-poisoning comprise a distinct but understudied group. The predominant absence of guideline-concordant pharmacologic care comprises a crucial target for future policy and knowledge translation efforts.

Meta-analysis of the Interval between the Onset and Management of Bipolar Disorder

OBJECTIVE

To evaluate the length of the interval between the onset and the initial management of bipolar disorder (BD).

METHOD

We conducted a meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches located studies reporting estimates of the age of onset (AOO) and indicators of the age at initial management of BD. We calculated a pooled estimate of the interval between AOO and age at management. Factors influencing between-study heterogeneity were investigated using sensitivity analyses, meta-regression, and multiple meta-regression.

RESULTS

Twenty-seven studies, reporting 51 samples and a total of 9415 patients, met the inclusion criteria. The pooled estimate for the interval between the onset of BD and its management was 5.8 years (standardized difference, .53; 95% confidence interval, .45 to .62). There was very high between-sample heterogeneity ( I² = 92.6; Q = 672). A longer interval was found in studies that defined the onset according to the first episode (compared to onset of symptoms or illness) and defined management as age at diagnosis (rather than first treatment or first hospitalization). A longer interval was reported among more recently published studies, among studies that used a systematic method to establish the chronology of illness, among studies with a smaller proportion of bipolar I patients, and among studies with an earlier mean AOO.

CONCLUSIONS

There is currently little consistency in the way researchers report the AOO and initial management of BD. However, the large interval between onset and management of BD presents an opportunity for earlier intervention.

Low self-recognition and awareness of past hypomanic and manic episodes in the general population

Background

Bipolar disorder is often underdiagnosed and undertreated. Its detection and correct diagnosis highly relies on the report of past hypomanic or manic episodes. We investigated the recognition and awareness of past hypomanic and manic episodes in a sample of respondents with bipolar disorder selected from a general population study.

Methods

In a reappraisal study from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), we further investigated 40 respondents with lifetime bipolar disorder confirmed by the structured clinical interview for DSM-IV (SCID). Respondents were asked about awareness of past depressive, manic and hypomanic episodes, illness characteristics and treatment history.

Results

Most respondents (82.5 %) recognized that they had experienced a depressive episode while 75 % had consulted a health professional for a depressive episode. Only a minority (22.5 %) recognized that they had experienced a (hypo)manic episode and only 17.5 % had consulted a health professional for a (hypo)manic episode. Only 12.5 % of the respondents reported having received a diagnosis of bipolar disorder. Recognition of previous (hypo)manic episodes was not related to severity of bipolar disorder.

Conclusions

In routine clinical practice history-taking on a syndromal level, i.e., only inquiring whether a patient presenting with depression ever experienced a hypomanic or manic episode or received treatment for such an episode, is not sufficient to confirm or exclude a diagnosis of bipolar disorder. Other efforts, such as an interview with a significant other and the use of self report questionnaires or (semi-)structured interviews may be needed to recognize previous manic symptoms in patients with depression.

International prescribing patterns for mood illness: the International Mood Network (IMN)

OBJECTIVE

To show the feasibility of creating an international network that will build a common database for mood disorders research, and to present initial data on prescribing patterns worldwide.

METHODS

An international research database was organized with clinicians and researchers actively treating mood disorders. Participating sites were asked to provide data on 10-50 subjects initially. This work was conducted under the auspices of a committee with representatives from North and South America, Europe, and Asia. Data was pooled from multiple sites using a centralized online system and then analyzed. Each site received IRB approval for its participation in the IMN and the Tufts Medical Center IRB provided approval for the entire project.

LIMITATIONS

More than half of the population came from one country (United States) and there is the possibility of cultural bias.

RESULTS

Among the 186 subjects enrolled in the IMN, a majority of subjects were prescribed mood stabilizers including lithium (64%), lamotrigine (37%), valproate (31%), and carbamazepine (3%). 79% had a diagnosis of bipolar disorder type I, II or NOS and 21% had a diagnosis of MDD. 81% of subjects used antidepressants at some point. 25% experienced antidepressant-induced mania and 26% had antidepressant-related rapid cycling. Mood stabilizers were prescribed more in Europe (86%), neuroleptics in South America (70%), and antidepressants in Asia (58%).

CONCLUSIONS

The results confirm the diversity and feasibility of an international mood disorders database. Important regional differences in psychotropic drug treatment of mood illnesses were observed, with more mood stabilizer use in Europe and South America, and more antidepressant use in non-European populations.

Psychotherapy use in bipolar disorder: Association with functioning and illness severity

OBJECTIVE

This study examines characteristics of individuals with bipolar disorder who sought psychotherapy versus those who did not.

METHODS

Bipolar CHOICE was an 11-site comparative effectiveness study of lithium versus quetiapine in symptomatic outpatients (N = 482) with bipolar disorder. At baseline, participants' psychotherapy use within the past 3 months, mood, functioning, and overall health were assessed. Logistic regressions were used to test whether psychotherapy users and non-users differed on various demographic and clinical variables at baseline. Mixed-effects regression was used to determine whether psychotherapy groups differed on response to treatment over the 6-month study. Kaplan-Meier plots and log-rank tests were employed to test whether there were any differences in time to recovery (CGI-BP ≤ 2 for at least 8 weeks) between the groups.

RESULTS

Thirty one percent of participants reported using psychotherapy services. Psychotherapy users reported greater medication side effect burden than non-users and were more likely to have moderate to high suicide risk and at least one anxiety disorder. Participants not utilizing medications or psychotherapy had greater mania symptom severity, were younger, and less educated than medication only users. Medication only users were more likely to be married than the other participants.

CONCLUSIONS

These data suggest that a minority of individuals with bipolar disorder attend psychotherapy services, and those that do have greater illness burden.

From self-care to hospitalization: bipolar patients' health care practices in Mexico

BACKGROUND

New research is continually improving the comprehension of bipolar disorder (BD). However, many challenges remain to be addressed, such as understanding the health care practices (HCPs) chosen by bipolar patients and the determinants of seeking treatment.

MATERIAL

Using a qualitative approach, we studied the HCPs of six patients with BD through focused interviews.

DISCUSSION

Even patients who report using primarily allopathic care usually test out and combine different HCPs.

CONCLUSION

Pathways to care in BD are composed of a combination of HCPs because patients need to develop a stock of potential treatment alternatives to deal with the suffering involved in living with BD.

Duration of untreated bipolar disorder: missed opportunities on the long road to optimal treatment

OBJECTIVE

Duration of untreated illness represents a potentially modifiable component of any diagnosis-treatment pathway. In bipolar disorder (BD), this concept has rarely been systematically defined or not been applied to large clinically representative samples.

METHOD

In a well-characterized sample of 501 patients with BD, we estimated the duration of untreated bipolar disorder (DUB: the interval between the first major mood episode and first treatment with a mood stabilizer). Associations between DUB and clinical onset and the temporal sequence of key clinical milestones were examined.

RESULTS

The mean DUB was 9.6 years (SD 9.7; median 6). The median DUB for those with a hypomanic onset (14.5 years) exceeded that for depressive (13 years) and manic onset (8 years). Early onset BD cases have the longest DUB (P < 0.0001). An extended DUB was associated with more mood episodes (P < 0.0001), more suicidal behaviour (P = 0.0003) and a trend towards greater lifetime mood instability (e.g. rapid cycling, possible antidepressant-induced mania).

CONCLUSION

Duration of untreated bipolar disorder (DUB) will only be significantly reduced by more aggressive case finding strategies. Reliable diagnosis (especially for BD-II) and/or instigation of recommended treatments is currently delayed by insufficient awareness of the early, polymorphous presentations of BD, lack of systematic screening and/or failure to follow established guidelines.

La psychoéducation pour les troubles bipolaires : recension des écrits et recommandations pour le système de santé québécois

Le trouble bipolaire est une maladie chronique caractérisée par une récurrence des rechutes thymiques, et par des symptômes résiduels interférant avec le fonctionnement de l’individu. La pharmacothérapie demeure la pierre angulaire du traitement. Malheureusement, la médication a des effets limités sur certains aspects de la maladie, sans compter qu’une grande proportion de patients présente des problèmes d’observance à leur traitement pharmacologique. Cette recension des écrits aborde le rôle de la psychoéducation comme traitement complémentaire dans la prise en charge des patients bipolaires. Les différentes modalités de psychoéducation structurée, dont deux programmes psychoéducatifs manualisés appuyés par des données probantes, sont présentées. Dans une perspective de transfert des connaissances, des recommandations pour l’implantation de la psychoéducation dans le système de santé québécois sont proposées.

Characteristics of bipolar disorder patients given antidepressants

Evidence concerning efficacy of antidepressants in bipolar disorder remains inconsistent and inconclusive. As the appropriate clinical use for such patients remains unclear, we characterized outpatients with bipolar disorders who were or were not treated with antidepressants. Clinical data were collected systematically from consecutive outpatients in 11 participating Argentine mood-disorder clinics in 2007-2008. Diagnoses met DSM-IV criteria, supported by structured interviews based on the MINI-500. Of 338 outpatients diagnosed with bipolar I (45.0%), II (29.3%), or not-otherwise-specified (NOS) (25.7%) disorder, 128 (37.9%) received antidepressants. Subjects given antidepressants or not did not differ significantly by presence or severity of current depression or being suicidal but were more likely to be women. Bipolar I disorder patients were three times less likely than types II or NOS to receive an antidepressant, with or without a mood-stabilizer or antimanic agent. Despite inconclusive evidence for efficacy and safety of antidepressants in various phases of bipolar disorders, 37.9% of such patients were receiving an antidepressant in 11 Argentine outpatient clinics. Antidepressant treatment was least likely with type I disorder and was independent of current depression and not associated with more use of mood-stabilizing or antimanic agents.

Bipolar disorder among adolescents and young adults: results from an epidemiological sample

BACKGROUND

Over the past decade, the clinical recognition and treatment of bipolar disorder (BD) in youth have increased significantly; however, little is known about prevalence of and service use for this disorder at a population level. The objective of this study was to measure the lifetime prevalence of BD, and to describe the socio-demographics, comorbidities, and use of mental health services among 15-24-year-olds with BD.

METHODS

Data were extracted from the Canadian Community Health Survey: Mental Health and Well-being (CCHS 1.2), a representative population-based survey of 36,984 people age 15 and older. Among subjects age 15-18 and 19-24 (N=5673), we calculated lifetime prevalence rates of BD and report the demographic and clinical characteristics and rates of service use of this sample.

RESULTS

The weighted lifetime prevalence of BD was 3.0% among 15-24-year-olds (N=191): 2.1% among 15-18-year-olds, and 3.8% among 19-24-year-olds. Rates of psychiatric comorbidity were high, with anxiety disorders, problematic substance use, and suicidality present among nearly half of the sample. Mental health services were accessed in the previous 12 months by 56.1% of youth with BD.

LIMITATIONS

The questionnaire used in CCHS 1.2 relied on self-report, limiting its applicability to this younger sample.

CONCLUSIONS

BD is particularly common among young adults and there are specific factors associated with BD in youth. Nearly half of all youth with BD have never used mental health services, suggesting that clinicians should be more vigilant about the signs and symptoms of BD in young people.

A population-based analysis of distinguishers of bipolar disorder from major depressive disorder

BACKGROUND

Many people with bipolar disorder (BD) in the community are misdiagnosed with major depressive disorder (MDD). A probabilistic model has been proposed to assist in the identification of BD among patients with depressive symptoms, however there are limited population-based data on the key distinguishers of BD from MDD. The objective of this study was to identify distinguishers of BD from MDD in a population-based sample.

METHODS

Population-based data were extracted from the Canadian Community Health Survey: Mental Health and Well-Being. Sociodemographic variables, clinical variables, and depressive symptomatology were compared between subjects with BD (N=467) and MDD (N=4145). Logistic regression analysis was used to identify significant correlates of BD, and areas under the receiver operating characteristic curves (AUCs) were determined for each model.

RESULTS

BD and MDD subjects differed across a number of characteristics. Clinical variables significantly associated with BD included greater number of lifetime depressive episodes, earlier age of first depressive episode, lifetime anxiety disorder, problematic substance use, and lifetime suicide attempt. Symptoms significantly more common during a major depressive episode among BD subjects included agitation, suicidal ideation, anxious symptoms, and irritability. AUCs for these models ranged from 0.72 to 0.81.

LIMITATIONS

Data were not available for all potential distinguishers; subgroups of BD could not be determined; cross-sectional data.

CONCLUSIONS

These population-based results reinforce the effort to establish a generalizable probabilistic model that incorporates clinical and symptom variables in order to assist clinicians in the diagnostic assessment of BD.

Differences in prevalence and treatment of bipolar disorder among immigrants: results from an epidemiologic survey

OBJECTIVE

To add to the limited data on the prevalence, clinical characteristics, and treatment of bipolar disorder (BD) among immigrants.

METHOD

Data were obtained from a large epidemiologic survey, the Canadian Community Health Survey-Mental Health and Well-Being (CCHS 1.2). Lifetime prevalence rates of BD were compared between immigrant and nonimmigrant respondents. Among BD subjects (n = 831), sociodemographic, clinical, and mental health treatment use variables were compared based on immigrant status. Logistic regression was used to determine the correlates of lifetime contact with a mental health professional and 12-month psychotropic medication use.

RESULTS

Lifetime prevalence rate of CCHS 1.2-defined BD was significantly lower among immigrant, compared with nonimmigrant, participants (1.50% and 2.27%, P = 0.01). There were few sociodemographic or clinical differences, yet immigrants with BD were significantly less likely to report any lifetime contact with mental health professionals (OR = 0.25, 95% CI 0.13 to 0.50, P < 0.001). Past-year psychotropic medication use was numerically lower among immigrants with BD (24.5% and 41.0%); however, this did not reach statistical significance when controlling for other factors (OR = 0.49, 95% CI 0.24 to 1.01, P = 0.05).

CONCLUSIONS

Based on the results of this study, there are in the range of 56 000 to 104 000 immigrants with BD in Canada. Further efforts are needed to better understand and address the barriers to mental health treatment use among immigrants who have BD.

Factors associated with use of mental health services for depressed and/or suicidal youth aged 15-24

Using data from a national survey, this study examined different factors and their association with mental health service use in youth aged 15-24 with depression and/or suicidality. Our sample consisted of 1,252 youth with depression and/or suicidality. In youth aged 15-18 years old, two factors influenced service use: (1) co-occurrence of depression and suicidality (OR 3.23, 95% CI 1.43, 7.32) and (2) chronic health condition (OR 2.44, 95% CI 1.22, 4.84). Several factors were associated with service use in youth aged 19-24 including gender (female) (OR 1.77, 95% CI 1.14, 2.76), and low income (OR 1.89, 95% CI 1.11, 3.23). The findings suggest differences in the factors associated with mental health service use between youth aged 15-18 and 19-24 with depression and/or suicidality.

Mood and anxiety disorders and the use of services and psychotropic medication in an immigrant population: findings from the Israel National Health Survey

OBJECTIVE

Using the Israel National Health Survey (INHS), we compared immigrants' 12-month prevalence of mental disorders and the use of services and psychotropic drugs with that of the general population.

METHODS

A representative sample of noninstitutionalized residents, aged 21 years and older, was drawn from the National Population Register. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders were assessed using a revised version of the Composite International Diagnostic Interview. Respondents were asked to report any health service and psychotropic drug use in the past 12 months.

RESULTS

During the 12 months preceding the INHS, immigrants and Israelis (that is, those born in Israel or those who emigrated to Israel before 1989) were equally likely to have a common mental disorder (OR 0.9; 95% CI 0.7 to 1.1) and to use health services (OR 0.9; 95% CI 0.7 to 1.2). However, among respondents who did not meet the DSM-IV criteria for a specific mental disorder, the immigrants reported markedly more use of psychotropic drugs than the Israelis, in particular more anxiolytics, mood stabilizers, and hypnotics.

CONCLUSION

The results suggest that the common mental disorders and mental health service use among the immigrants are no higher than that among their Israeli counterparts. The higher use of psychotropic drugs by immigrants may be an indirect indicator of a higher level of psychological distress symptoms, such as anxiety, depression, and sleep disorders.

Clinical practice recommendations for bipolar disorder

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

The treated prevalence and incidence of bipolar disorder among national health insurance enrollees in Taiwan, 1996-2003

We used the NHI database to estimate the treated prevalence and incidence of bipolar disorder. The national health research institute (NHRI) provided a population based data file of 200,432 random subjects, about 1% of the population, for the study. We obtain a random sample of 136,045 subjects as a fixed cohort from 1996 to 2003. We identified study subjects who had at least one service claim during these years for either ambulatory or inpatient care with a principal diagnosis of bipolar disorder. The cumulative treated prevalence increased from 0.60 per 1,000 to 4.51 per 1,000 from 1996 to 2003. The annual treated incidence was around 0.48 per 1,000 per year to 0.71 per 1,000 per year during 1997-2003. Higher treated incidence was detected in the 45-64 (hazard ratio [HR], 1.63; 95% CI, 1.26-2.12) and 65 years or older age groups (HR, 1.57; 95% CI, 1.14-2.15), female (HR, 1.23; 95% CI, 1.04-1.46), non-aborigine (HR, 3.12; 95% CI, 1.26-7.75), with a fixed premium (HR, 1.60; 95% CI, 1.18-2.17), and those who lived in the eastern region (HR, 3.26; 95% CI, 2.31-4.59). According to the trends from 1996 to 2003, more persons with bipolar disorder had sought treatment in the NHI program in Taiwan. However, the treated prevalence of bipolar disorder in NHI was still lower than those of community studies in Western countries. In the future, we will continue to use NHI data to perform outcome evaluation and follow-up studies of bipolar disorder.