Long-term Effectiveness and Cost of a Systematic Care Program for Bipolar Disorder

Center for Health Studies, Group Health Cooperative, and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98101, USA.
Archives of General Psychiatry (Impact Factor: 14.48). 06/2006; 63(5):500-8. DOI: 10.1001/archpsyc.63.5.500
Source: PubMed


Despite the availability of efficacious treatments, the long-term course of bipolar disorder is often unfavorable.
To test the effectiveness of a multicomponent intervention program to improve the quality of care and long-term outcomes for persons with bipolar disorder.
Randomized controlled trial with allocation concealment and blinded outcome assessment.
Mental health clinics of a group-model prepaid health plan.
Of 785 patients in treatment for bipolar disorder who were invited to participate, 509 attended an evaluation appointment, 450 were found eligible to participate, and 441 enrolled in the trial.
Participants were randomly assigned to a multicomponent intervention program or to continued care as usual. Three nurse care managers provided a 2-year systematic intervention program, including the following: a structured group psychoeducational program, monthly telephone monitoring of mood symptoms and medication adherence, feedback to treating mental health providers, facilitation of appropriate follow-up care, and as-needed outreach and crisis intervention.
In-person blinded research interviews every 3 months assessed mood symptoms using the Longitudinal Interval Follow-up Examination. Health plan administrative records were used to assess the use and cost of mental health services.
Intent-to-treat analyses demonstrated that the intervention significantly reduced the mean level of mania symptoms (z = 2.09, P = .04) and the time with significant mania symptoms (19.2 vs 24.7 weeks; F(1) = 6.0, P = .01). There was no significant intervention effect on mean level of depressive symptoms (z = 0.19, P = .85) or time with significant depressive symptoms (47.6 vs 50.7 weeks; F(1) = 0.56, P = .45). Benefits of the intervention were found only in a subgroup of 343 persons with clinically significant mood symptoms at the baseline assessment. The incremental cost (adjusted) of the intervention was 1251 dollars (95% confidence interval, 55-2446 dollars), including approximately 800 dollars for the intervention program services and an approximate 500 dollars increase in the costs of other mental health services.
Population-based systematic care programs can significantly reduce the frequency and severity of mania in bipolar disorder, and cost increases are modest considering the clinical gains. The incorporation of more specific cognitive and behavioral content or more effective medication regimens may be necessary to significantly reduce the symptoms of depression.

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    • "Compared to usual care, LG improved outcomes among a cross-diagnosis sample of community-based outpatients with mood disorders [45–49,52], notably a four-point increase in mental and physical health-related quality of life scores based on the SF-12 (e.g., Cohen’s D = .36) [45,46,49]. LG has been shown to be equally effective in patients with co-occurring substance use and medical comorbidities [46,47,49,52,61]. Community-based providers helped to adapt LG [46–48], but as with many psychosocial EBPs, have not been widely implemented in smaller practices [62]. "
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    ABSTRACT: Background Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.Methods/DesignThis study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N¿=¿1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ¿3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.DiscussionThis study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.Trial identifier: NCT02151331.
    Implementation Science 09/2014; 9(1):132. DOI:10.1186/s13012-014-0132-x · 4.12 Impact Factor
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    • "Collaborative Care Models (CCMs) [11], which provide proactive care for patients through self-management education, coordination of services, and ongoing follow-up with patients and communications with providers by a care manager have been shown to improve medical and psychiatric outcomes, primarily for patients with depression [12]. More recently, Life Goals Collaborative Care (LG-CC), a CCM-based intervention developed to address physical health and CVD risk in patients with bipolar disorder, led to improved mental health physical health outcomes [13] [14] [15] [16]. LG-CC adds components of health behavior change to the CCM components, notably by linking symptom management with healthy behavior goal-setting, as well as follow-up on physical and mental health symptoms and care. "
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    ABSTRACT: Background Persons with serious mental illnesses (SMI) are more likely to die earlier than the general population, primarily due to increased medical burden, particularly from cardiovascular disease (CVD). Life Goals Collaborative Care (LG-CC) is designed to improve health outcomes in SMI through self-management, care management, and provider support. This single-blind randomized controlled effectiveness study will determine whether patients with SMI receiving LG-CC compared to usual care (UC) experience improved physical health in 12 months. Methods Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or UC. LG-CC included five self-management sessions covering mental health symptom management reinforced through health behavior change; care coordination and health monitoring via a registry, and provider feedback. The primary outcome is change in physical health-related quality of life score (VR-12) from baseline to 12 months. Secondary outcomes include changes in mental health-related quality of life, CVD risk factors (blood pressure, BMI), and physical activity from baseline to 12 months later. Results Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N = 284); the mean age was 55.2 (SD = 10.9; range 28–75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean ± SD = 33.3 ± 6.3). Baseline VR-12 physical health component score was below population norms (50.0 ± SD = 10) at 33.4 ± 11.0. Conclusions Findings from this trial may inform initiatives to improve physical health for SMI patient populations.
    Contemporary Clinical Trials 09/2014; 39(1). DOI:10.1016/j.cct.2014.07.007 · 1.94 Impact Factor
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    • "Although most randomized controlled trials have been tested on depression, two trials (Bauer et al. 2006a; Simon et al. 2006) have tested the effectiveness of collaborative models for adults with bipolar disorder. These trials have shown improvements in clinical outcomes, social role functioning, quality of life, and general patient satisfaction (Bauer et al. 2006b; Bauer et al. 2009; Kilbourne et al. 2008; Simon et al. 2006). Second, there is a need to tailor treatments to meet the needs of adolescents, minorities, and disabled children. "
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    ABSTRACT: This study examined conformance to clinical practice guidelines for children and adolescents with bipolar disorders and identified patient and provider factors associated with guideline concordant care. Administrative records were examined for 4,047 Medicaid covered youth aged 5-18 years with new episodes of bipolar disorder during 2006-2010. Main outcome measures included 5 claims-based quality of care measures reflecting national treatment guidelines. Measures addressed appropriate pharmacotherapy, therapeutic drug monitoring, and psychosocial treatment. The results indicated that current treatment practices for youth diagnosed with bipolar disorder typically fall short of recommended practice guidelines. Although the majority of affected youth are treated with recommended first-line pharmacotherapy, only a minority receive therapeutic drug monitoring and/or psychotherapy of recommended duration, underscoring the need for quality improvement initiatives.
    Administration and Policy in Mental Health and Mental Health Services Research 04/2014; 42(2). DOI:10.1007/s10488-014-0553-5 · 3.44 Impact Factor
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