Working, receiving disability benefits, and access to mental health care in individuals with bipolar disorder

OBJECTIVE: The objective of this study was to determine the extent to which people in a bipolar disorder (BPD) registry were working, factors associated with working and obtaining disability benefits, and the impact disability benefits have on work. METHODS: We compared the socio-demographic, disease, treatment, and health insurance characteristics among three work disability groups - working, not working, and not working and receiving disability benefits - using a chi-square statistical test on categorical data, one-way analysis of variance (ANOVA) to compare means, and a Kruskal-Wallis non-parametric test of significance with skewed data. RESULTS: Among 1,855 individuals, 49.4% reported they were working. Those working were younger, more frequently self-identified as Caucasian, were more highly educated, had a higher income, were more often married, had a shorter duration of illness, and reported the shortest illness duration, the lowest percentage of suicide attempts, and manic and mixed or rapid symptoms in the past 6 months compared to the two non-working groups. Working individuals least often reported receiving electroconvulsive therapy and being hospitalized and had the longest median duration since last hospitalization and the lowest percentage with treatment in the past 6 months. They were currently likelier to be treated by a primary care physician or other health professional than a psychiatrist compared to non-working groups. Finally, compared to the non-working groups, the working group had the highest percentage with no health insurance and private health insurance, the highest percentage using managed care, and the lowest percent under a fee-for-service plan. All work disability groups had similar perceptions of their mental health care plan in terms of the number of doctors or clinics from which to choose, the location of their health care providers, and the quality of mental health care. Those in the working group were least satisfied with the range of mental health services provided in their health plan. CONCLUSIONS: Disability benefits are rarely awarded when a person is working. Moreover, receipt of disability benefits increases the likelihood that a person with BPD will be receiving health care benefits and, in many cases, those benefits provide greater access to treatment compared to health care insurance received through an employer. We conclude that the incentives to work run counter to access to treatment among people with BPD.     

Illness experience and reasons for nonadherence among individuals with bipolar disorder who are poorly adherent with medication

Aim

Nonadherent individuals are the most likely to avoid participating in research studies, thus limiting potential opportunities to develop evidence-based approaches for adherence enhancement. This mixed-method analysis evaluated factors related to adherence among 20 poorly adherent community mental health clinic patients with bipolar disorder (BD).

Methods

Illness experience was evaluated with qualitative interview. Quantitative assessments measured symptoms (Hamilton Depression Rating Scale, Young Mania Rating Scale, Brief Psychiatric Rating Scale), adherence behavior, and treatment attitudes. Poor adherence was defined as missing 30% or more of medication.

Results

Minorities (80%), unmarried individuals (95%), and those with substance abuse (65%) predominated in this nonadherent group of patients with BD. Individuals were substantially depressed (mean Hamilton Depression Rating Scale, 19.2), had at least some manic symptoms (mean Young Mania Rating Scale, 13.6), and had moderate psychopathology (mean Brief Psychiatric Rating Scale, 41.2). Rates of missed medications were 41% to 43%. Forgetting to take medications was the top reason for nonadherence (55%), followed by side effects (20%). Disorganized home environments (30%), concern regarding having to take long-term medications (25%) or fear of side effects (25%), and insufficient information regarding BD (35%) were relatively common. Almost one third of patients had individuals in their core social network who specifically advised against medication. Access problems included difficulty paying for medications among more than half of patients. Interestingly, patients reported good relationships with their providers.

Conclusions

Forgetting to take medication and problems with side effects are primary drivers of nonadherence. Lack of medication routines, unsupportive social networks, insufficient illness knowledge, and treatment access problems may likewise affect overall adherence. Complementary quantitative and qualitative data collection can identify reasons for nonadherence and may inform specific clinical approaches to enhance adherence.     

Factors associated with prospective long-term treatment adherence among individuals with bipolar disorder

OBJECTIVE: Clinical characteristics, adverse effects of medication, and treatment attitudes have been associated with adherence in bipolar populations in cross-sectional studies. The aim of this secondary analysis from a larger study was to identify the association between baseline variables and average treatment adherence over a subsequent three-year period. METHODS: Veterans with bipolar disorder were evaluated on self-reported adherence status at baseline and every six months over a three-year period. The sample was dichotomized into two clinically relevant categories: those who were primarily adherent and those who were primarily nonadherent. Demographic and clinical variables were examined for the two groups of patients in relation to their average adherence over the three-year period. RESULTS: The study recruited a sample of 306 persons with severe bipolar disorder. The sample was predominantly male (278 men, or 91%), with a mean+/-SD age of 46.6+/-10.1 years. A total of 240 individuals (78%) were largely adherent to treatment, and 37 individuals (12%) were largely nonadherent to treatment. Nonadherent individuals were less likely to be on intensive somatotherapy regimens (p=.001); experienced more barriers to care, including lack of telephone access (p<.05) and life obligations and commitments (p<.05); and had more prior suicide attempts (p=.003). CONCLUSIONS: Nonadherent individuals with bipolar disorder received less intensive pharmacologic treatments, had more suicide attempts, and experienced more barriers to care than adherent individuals. Nonadherence may have system as well as patient components. Consideration of nonadherence as a function of both patient factors and system factors will enhance our ability to understand nonadherence and intervene more effectively.     

Predictors of suicide in a community-based cohort of individuals with severe mental disorder

Background Rate of suicide is probably an indicator of the quality of mental health services within an area. The aim of this study was to identify predictors of suicide in a large community-based cohort of persons with long-term mental disorder.Methods A survey was conducted in Stockholm County, Sweden, in 1997 to identify adults with long-term disabling mental disorder (mental retardation and dementia excluded). The survey included an inventory of unmet needs as perceived by the service providers. The 12,247 cases were linked to the national in-patient register and the cause-of-death register. Predictors of suicide in 1997–2000 were determined by bivariate analysis and multiple logistic regression.Results Predictors of suicide included a history of in-patient psychiatric care, previous suicide attempt, substance abuse and unmet need of a contact person. Personality disorder, especially borderline personality disorder, was the strongest diagnostic predictor of suicide among those with a history of in-patient psychiatric care.Conclusion Unmet needs may signal increased suicide risk in persons with severe mental disorder. Methods to improve suicide prevention in persons with personality disorder should be further developed. Interventions to reduce suicide in persons with a long-term mental disorder will require collaboration between psychiatric and social services.     

Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder

BACKGROUND: Few studies have evaluated medication adherence among older vs younger individuals with bipolar disorder (BPD). We compared adherence with antipsychotic medication among older (age 60 and older) and younger individuals using a large case registry (n = 73,964). METHODS: Adherence was evaluated using the medication possession ratio (MPR) for patients receiving antipsychotic medication. RESULTS: Twenty six thousand five hundred and thirty younger individuals (mean age 46.9) and 6,461 older individuals (mean age 69.2) were prescribed antipsychotic medication. Among older individuals, 61.0% (n = 3,350) were fully adherent, while 19.0% (n = 1,043) were partially adherent and 20.0% (n = 1,098) were non-adherent. Among younger individuals, 49.5% (n = 10,644) were fully adherent, while 21.8% (n = 4,680) were partially adherent, and 28.7% (n = 6,170) were non-adherent. As with younger patients, comorbid substance abuse and homelessness predicted non-adherence among older patients with BPD. CONCLUSION: Older individuals with BPD were more adherent with antipsychotic medications compared to younger individuals. However, a substantial proportion (approximately 39%) of older patients with BPD still have difficulties with adherence.     

Return to treatment after assessment in a community children's mental health clinic

Most people who receive mental health assessments do not follow up on needed treatment. The authors examined factors that predicted return for at least one treatment visit among 113 children who presented for treatment at a rural community mental health center, using predictors of return for adults from a previous study. Sixty-four percent of the children, compared with 46 percent of the adults, returned at least once. Time until the first appointment predicted whether patients returned for treatment. The age of the child was the only other variable that predicted initial treatment engagement. The results strongly suggest that community mental health agencies can improve treatment acceptance rates by providing rapid response to requests for treatment.     

Intake procedures at a community mental health clinic

It is suggested that it is necessary to modify classical techniques so that the responsibility for the care of large numbers of people can be discharged. One approach has been practiced for three years at the North Suffolk Mental Health Center in Boston. This method allows for diagnostic procedures to be integrated with administrative follow through enabling a family to be helped rapidly. After three years, this approach has made it possible to see more than 700 families without a waiting list and with a possibility of making diagnoses within the major diagnostic categories of child pathology. This procedure has been an important reason for a positive relationship with the community and has enabled the Center to enter areas of consultation and education more easily.     

Burden of general medical conditions among individuals with bipolar disorder

OBJECTIVE: Treatment of coexisting medical comorbidities may reduce the risk of adverse outcomes among patients with bipolar disorder. We determined the prevalence of general medical conditions in a population-based sample of patients diagnosed with bipolar disorder in the Veterans Administration (VA). METHODS: We conducted a cross-sectional study of patients (n = 4310) diagnosed with bipolar disorder in fiscal year 2001 receiving care at VA facilities located within the mid-Atlantic region. General medical conditions were assessed using ICD-9 codes, and we compared the prevalence of each condition in our bipolar sample with national data on the VA patient population. RESULTS: The mean age was 53 (SD = 13), 10% were women, and 12% African-American. The mean age of the VA national patient population was higher (58 years). The most prevalent conditions among patients with bipolar disorder included cardiovascular (e.g. hypertension, 35%), endocrine (e.g. hyperlipidemia, 23%; diabetes, 17%), and alcohol use disorder (25%). When compared with national data, the prevalence of diabetes was higher in the bipolar cohort than in the national cohort (17.2% versus 15.6%; p = 0.0035). Hepatitis C was more common in the bipolar group than the national cohort (5.9% versus 1.1%; p < 0.001). Lower back pain (15.4% versus 10.6%; p < 0.0001) and pulmonary conditions (e.g. COPD: 10.6% versus 9.4%; p = 0.005) were also more prevalent among the bipolar cohort than the VA national cohort. CONCLUSIONS: Individuals with bipolar disorder possess a substantial burden of general medical comorbidity, and are occurring at an earlier age than in the general VA patient population, suggesting the need for earlier detection and treatment for patients with bipolar disorder.     

Comparing diagnostic checklists for pediatric bipolar disorder in academic and community mental health settings

OBJECTIVES: To compare six promising mania measures, the Parent Mood Disorder Questionnaire (P-MDQ), the Adolescent self-report MDQ, the 10-item short form of the Parent General Behavior Inventory (PGBI-SF10), the 28-item Adolescent General Behavior Inventory (AGBI), the Parent Young Mania Rating Scale (P-YMRS), and the adolescent YMRS, in a demographically diverse outpatient sample. METHODS: Participants were 262 outpatients (including 164 males and 131 African-Americans) presenting to either an academic medical center (n = 153) or a community mental health center (n = 109). Diagnoses were based on semi-structured interviews with the parent and then youth sequentially. RESULTS: Ninety youths (34%) met criteria for a bipolar spectrum disorder. Parent measures yielded Areas Under the Receiver Operating Curve (AUROC) values of 0.81 for the PGBI-SF10 to 0.66 for the P-YMRS. Adolescent report measures performed significantly less well, with AUROCs ranging from 0.65 to 0.50. There were no significant differences in the diagnostic performance of the measures across the sites or by racial groups, although the reliability of measures tended to be lower in the urban community mental health site. The PGBI-SF10 made a significant contribution to logistic regression models examining all combinations of the instruments. The P-MDQ added information in the younger age group, and no measure improved classification of bipolar cases after controlling for the PGBI-SF10 in the older age group. DISCUSSION: Results replicate previous findings that, in decreasing order of efficiency, the PGBI-SF10, P-MDQ, and P-YMRS significantly discriminate bipolar from non-bipolar cases in youths aged 5-18; and they appear robust in a demographically diverse community setting. Adolescent self-report measures are significantly less efficient, sometimes performing no better than chance at detecting bipolar cases.     

Posttraumatic stress disorder among African Americans in an inner city mental health clinic

This study examined 184 African-American outpatients in a mental health clinic in the inner city to define the rate of occurrence of traumatic experience and posttraumatic stress disorder (PTSD). This population experienced a high rate of severe trauma. Forty-three percent were found to have PTSD, as measured by the PTSD Symptom Scale. Finally, a chart review of 72 participants found that only 11 percent of participants who met DSM-IV criteria for PTSD also had a chart diagnosis of PTSD. PTSD is a common yet underrecognized and undertreated source of psychiatric morbidity in this urban community of African Americans with low socioeconomic status.     

Sustained attention deficits among HIV-positive individuals with comorbid bipolar disorder

Difficulties with sustained attention have been found among both persons with HIV infection (HIV+) and bipolar disorder (BD). The authors examined sustained attention among 39 HIV+ individuals with BD (HIV+/BD+) and 33 HIV-infected individuals without BD (HIV+/BD-), using the Conners' Continuous Performance Test-II (CPT-II). A Global Assessment of Functioning (GAF) score was also assigned to each participant as an overall indicator of daily functioning abilities. HIV+/BD+ participants had significantly worse performance on CPT-II omission errors, hit reaction time SE (Hit RT SE), variability of SE, and perseverations than HIV+/BD- participants. When examining CPT-II performance over the six study blocks, both HIV+/BD+ and HIV+/BD- participants evidenced worse performance on scores of commission errors and reaction times as the test progressed. The authors also examined the effect of current mood state (i.e., manic, depressive, euthymic) on CPT-II performance, but no significant differences were observed across the various mood states. HIV+/BD+ participants had significantly worse GAF scores than HIV+/BD- participants, which indicates poorer overall functioning in the dually-affected group; among HIV+/BD+ persons, significant negative correlations were found between GAF scores and CPT-II omission and commission errors, detectability, and perseverations, indicating a possible relationship between decrements in sustained attention and worse daily-functioning outcomes.     

Attitudes regarding the collaborative practice model and treatment adherence among individuals with bipolar disorder

An emerging literature suggests that a collaborative care model, in which patients are active managers of their illness within a supportive social environment, is a beneficial approach for individuals with bipolar disorder. One aspect of treatment that is often suboptimal among individuals with bipolar disorder is treatment adherence. Establishing an ideal collaborative model may offer an opportunity to enhance treatment adherence among individuals with bipolar disorder. This paper presents results from a qualitative exploration of patients' attitudes towards the collaborative care model and how individuals with bipolar disorder perceive treatment adherence within the context of the collaborative care model. All participants were actively enrolled in outpatient treatment at a Community Mental Health Center and part of a larger study that evaluated the Life Goals Program, a manual-driven structured group psychotherapy for bipolar disorder that is based on the collaborative practice model. The Life Goals Program is designed to assist individuals to participate more effectively in the management of their bipolar illness and to improve their social and work-related problems. Individuals were queried regarding their opinions on the ingredients for an effective client-provider relationship. Quantitative data were collected on baseline treatment adherence as well. Individuals treated for bipolar disorder in a community mental health clinic identified 12 key elements that they felt were critical ingredients to a positive collaborative experience with their mental health care provider. The authors conceptualized these elements around 3 emerging themes: patient-centered qualities, provider-centered qualities, and interactional qualities. Individuals with bipolar disorder perceived the ideal collaborative model as one in which the individual has specific responsibilities such as coming to appointments and sharing information, whereas the provider likewise has specific responsibilities such as keeping abreast of current "state-of-the-arf" prescribing practices and being a good listener. Treatment adherence was identified as a self-managed responsibility within the larger context of the collaborative model. Individuals with bipolar disorder in this study placed substantial emphasis on the interactional component within the patient-provider relationship, particularly with respect to times when the individual may be more symptomatic and more impaired. It is important that clinicians and care providers gather information related to patients' perceptions of the patient-provider relationship when designing or evaluating services aimed at enhancing treatment adherence.     

Obesity in bipolar disorder and major depressive disorder: results from a national community health survey on mental health and well-being.

OBJECTIVE: We aimed to ascertain the prevalence of obesity in individuals with a mood disorder (MD) (that is, bipolar disorder or major depressive disorder), compared with the general population. We further aimed to examine the likelihood of an association between obesity and MD, while controlling for the influence of sociodemographic variables. METHOD: The analysis was based on data from Statistics Canada's Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), conducted in 2002. The sample (n = 36 984; > or = aged 15 years) was drawn from the Canadian household-dwelling population. The CCHS used diagnostic criteria outlined in the DSM-IV to screen respondents. RESULTS: Individuals with a lifetime history of MD were more likely to be obese (body mass index [BMI] > 30) than were individuals without lifetime MD (19%, compared with 15%, respectively; P < 0.001). In sex-specific multivariate analysis, lifetime MD was associated with elevated odds of obesity in female respondents (95%CI, 1.03 to 1.46, odds ratio 1.22), but not in male respondents. Antipsychotic pharmacotherapy was also associated with obesity. CONCLUSIONS: This is the first Canadian epidemiologic investigation to specifically evaluate anthropometric indices and associated factors in people with MDs. The results herein supplement substantial clinical evidence documenting the association between MDs and stress-sensitive somatic disorders (for example, obesity). These data also underscore the metabolic consequences of some psychotropic agents.     

Relationship between criminal arrest and community treatment history among patients with bipolar disorder

OBJECTIVE: This study examined the relationship between criminal arrest and gender, substance use disorder, and use of community mental health services among patients with bipolar I disorder. METHODS: Los Angeles County's computerized management information system was used to retrospectively identify all inmates with a DSM-IV diagnosis of bipolar I disorder who were evaluated over a seven-month period in the psychiatric division of Los Angeles County Jail and had a history of psychiatric hospitalization in the community. Patients without a history of arrest who were involuntarily hospitalized in the community and treated for bipolar I disorder over the same seven-month period served as a comparison group. The use of community mental health services that inmates received before their arrest was quantified and compared with the services that patients in the comparison group received before their involuntary hospitalization. RESULTS: Patients who had been arrested (N = 66) were more likely than patients in the comparison group (N = 52) to be male (55 percent compared with 31 percent) and to have a history of substance use disorder (76 percent compared with 19 percent) but were less likely to have a history of treatment while under a mental health conservatorship (8 percent compared with 29 percent). In contrast to patients in the comparison group, patients who had been arrested were hospitalized more frequently (a mean of 3.4 hospitalizations per year compared with a mean of 1.1 hospitalizations per year) and had a briefer average length of stay (a mean of 9.2 days compared with a mean of 16.4 days). CONCLUSIONS: In contrast to patients in the comparison group, patients who had been arrested were more likely to be male, to have comorbid substance use disorder, and to have a treatment history characterized by more frequent, briefer hospitalizations.     

Predictors of appointment non-compliance in community mental health patients

This study identified two variables, unemployment and alcohol or substance abuse related diagnoses, to be the only predictors of appointment non-compliance out of various demographic and clinical variables. The results also indicate that appointment non-compliance should be treated as a continuous rather than a dichotomous are discussed. variable in future research. Programmatic implications for reducing non-compliance