Bipolar disorders: a review

Bipolar disorders are common, disabling, recurrent mental health conditions of variable severity. Onset is often in late childhood or early adolescence. Patients with bipolar disorders have higher rates of other mental health disorders and general medical conditions. Early recognition and treatment of bipolar disorders improve outcomes. Treatment of mood episodes depends on the presenting phase of illness: mania, hypomania, mixed state, depression, or maintenance. Psychotherapy and mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, are first-line treatments that should be continued indefinitely because of the risk of relapse. Monotherapy with antidepressants is contraindicated in mixed states, manic episodes, and bipolar I disorder. Maintenance therapy for patients involves screening for suicidal ideation and substance abuse, evaluating adherence to treatment, and recognizing metabolic complications of pharmacotherapy. Active management of body weight reduces complications and improves lipid control. Patients and their support systems should be educated about mood relapse, suicidal ideation, and the effectiveness of early intervention to reduce complications.     

Impact of Mental Disorders on Cost and Reimbursement for Patients in Inpatient Rehabilitation Facilities

Dobrez D, Heinemann AW, Deutsch A, Durkin EM, Almagor O. Impact of mental disorders on cost and reimbursement for patients in inpatient rehabilitation facilities.

Objective

To determine whether comorbid mental disorders affect inpatient rehabilitation facility (IRF) costs and to examine the extent to which Medicare's prospective payment system reimbursement sufficiently covers those costs.

Design

Secondary analysis of Medicare IRF Patient Assessment Instrument files and Medicare Provider and Review files. Payment was compared with costs for patients with and without reported mood, major depression, substance use, or anxiety disorders. The relationships among payment group assignment, comorbidity-related adjustments in payment, and the presence of mental disorders were estimated.

Setting

IRFs (N=1334) in the United States.

Participants

Medicare fee-for-service beneficiaries (N=1,146,799) discharged from IRFs from 2002 to 2004.

Interventions

Not applicable.

Main Outcome Measure

IRF costs.

Results

Mental disorders were reported for 13% of the Medicare fee-for-service beneficiaries. After controlling for payment group and comorbidity classifications, patients with mood, major depression, or anxiety disorders had significantly greater costs of $433, $1642, and $247 compared with patients without these disorders. The higher cost for patients with major depression (14.9% higher) is sufficient to justify a tier 2 comorbidity classification.

Conclusions

A reimbursement adjustment for the presence of a major depressive disorder would bring Medicare reimbursement in line with facility costs. The failure to compensate facilities directly for providing care to patients with major depression may result in reduced access to care for these patients. It also may create a disincentive to meet mental health treatment needs during the rehabilitative episode. Further work is needed to compare costs between patients with and without confirmed mental health disorders, given concerns about the accurate reporting of mental health disorders.     

Serum alcohol dehydrogenase levels in patients with mental disorders

Alcohol dehydrogenase (ADH) was assessed in 81 patients admitted to hospital for treatment for alcohol dependence with or without liver cirrhosis, 20 patients with bipolar disorder treated with lithium carbonate and 41 patients with various mental disorders treated with psychopharmacologic agents. Testing the hypothesis of the arithmetic mean showed that in alcohol dependents the arithmetic mean of ADH activity (12.19 nkat/l+/-5.61) differs significantly from that in healthy subjects (4.45 nkat/l+/-2.31) and in the group with ethanol poisoning (6.24 nkat/l+/-3.65) there is none. In the group with bipolar disorder, treated with lithium (7.39 nkat/l+/-3.11) and, in the group of patients treated with psychiatric drugs because of various mental disorders (7.79 nkat/l+/-8.51), the differences are statistically significant. In our opinion, assessing ADH activity in the sera of alcohol dependents could be an additional marker advantageous to the diagnostics, course and monitoring of therapy in such patients. In the groups of patients with mental disorders treated with psychotropic drugs, the increased ADH activity was found to be a more sensitive marker for the detection of drug hepatotoxicity.