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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    • "Manic prodromes are more distinct and may be easier to detect and treat more quickly and effectively with pharmacotherapy than depressive episodes[78]. On the contrary, depressive symptoms are more difficult to differentiate from normal day-to-day problems and may have a more gradual onset and prolonged duration[79]. Considering electronic selfmonitoring a psychological intervention, the potential harmful effects on depressive symptoms as suggested by the findings from the RCT by the authors[16]highlight that electronic self-monitoring should not be uncritically used or implemented in clinical practice and that important aspects need further clarification before it is implemented as a standard tool. If there would be an effect of electronic selfmonitoring on the severity of depressive or manic symptoms , then self-monitoring would influence the variables it measures (mood). "
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    ABSTRACT: Background Various paper-based mood charting instruments are used in the monitoring of symptoms in bipolar disorder. During recent years an increasing number of electronic self-monitoring tools have been developed. The objectives of this systematic review were 1) to evaluate the validity of electronic self-monitoring tools as a method of evaluating mood compared to clinical rating scales for depression and mania and 2) to investigate the effect of electronic self-monitoring tools on clinically relevant outcomes in bipolar disorder. Methods A systematic review of the scientific literature, reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted. MEDLINE, Embase, PsycINFO and The Cochrane Library were searched and supplemented by hand search of reference lists. Databases were searched for 1) studies on electronic self-monitoring tools in patients with bipolar disorder reporting on validity of electronically self-reported mood ratings compared to clinical rating scales for depression and mania and 2) randomized controlled trials (RCT) evaluating electronic mood self-monitoring tools in patients with bipolar disorder. Results A total of 13 published articles were included. Seven articles were RCTs and six were longitudinal studies. Electronic self-monitoring of mood was considered valid compared to clinical rating scales for depression in six out of six studies, and in two out of seven studies compared to clinical rating scales for mania. The included RCTs primarily investigated the effect of heterogeneous electronically delivered interventions; none of the RCTs investigated the sole effect of electronic mood self-monitoring tools. Methodological issues with risk of bias at different levels limited the evidence in the majority of studies. Conclusions Electronic self-monitoring of mood in depression appears to be a valid measure of mood in contrast to self-monitoring of mood in mania. There are yet few studies on the effect of electronic self-monitoring of mood in bipolar disorder. The evidence of electronic self-monitoring is limited by methodological issues and by a lack of RCTs. Although the idea of electronic self-monitoring of mood seems appealing, studies using rigorous methodology investigating the beneficial as well as possible harmful effects of electronic self-monitoring are needed.
    Full-text · Article · Dec 2016 · BMC Psychiatry
    • "The total time for each standard and enhanced REP component was recorded by study research assistants using a standardized form that was previously established for similar LG-CC implementation studies (Kilbourne et al. 2008, 2012, 2013; Simon et al. 2006). Total time spent on "
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    ABSTRACT: This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.
    No preview · Article · Oct 2014 · Administration and Policy in Mental Health and Mental Health Services Research
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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.
    Full-text · Article · Sep 2014 · Implementation Science
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