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Articles   |    
Use of Treatment Services in a Comparative Effectiveness Study of Bipolar Disorder
Louisa G. Sylvia, Ph.D.; Dan Iosifescu, M.D.; Edward S. Friedman, M.D.; Emily E. Bernstein, B.S.; Charles L. Bowden, M.D.; Terence A. Ketter, M.D.; Noreen A. Reilly-Harrington, Ph.D.; Andrew C. Leon, Ph.D.; Joseph R. Calabrese, M.D.; Michael J. Ostacher, M.D., M.P.H.; Dustin J. Rabideau, M.S.; Michael E. Thase, M.D.; Andrew A. Nierenberg, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200479
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Dr. Sylvia, Ms. Bernstein, Dr. Reilly-Harrington, and Dr. Nierenberg are with the Department of Psychiatry and Mr. Rabideau is with the Biostatistics Center, Massachussetts General Hospital, 55 Fruit Street, Boston, MA 02114 (e-mail: lsylvia2@partners.org). Dr. Iosifescu is with the Department of Psychiatry and Neuroscience at Mount Sinai Medical School, New York City. Dr. Friedman is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh. Dr. Bowden is with the Department of Psychiatry, University of Texas Health Sciences Center, San Antonio. Dr. Ketter and Dr. Ostacher are with the Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California. Dr. Leon, who passed away in 2012, was with the Department of Psychiatry, Weill Medical College of Cornell University, New York City. Dr. Calabrese is with the Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio. Dr. Thase is with the Department of Psychiatry, University of Pennsylvania, Philadelphia.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  Bipolar disorder is a severe, chronic mental illness with a high incidence of medical and psychological comorbidities that make treatment and prevention of future episodes challenging. This study investigated the use of services among outpatients with bipolar disorder to further understanding of how to maximize and optimize personalization and accessibility of services for this difficult-to-treat population.

Methods  The Lithium Treatment–Moderate Dose Use Study (LiTMUS) was a six-month multisite, comparative effectiveness trial that randomly assigned 283 individuals to receive lithium plus optimized care—defined as personalized, guideline-informed care—or optimized care without lithium. Relationships between treatment service utilization, captured by the Cornell Service Index, and demographic and illness characteristics were examined with generalized linear marginal models.

Results  Analyses with complete data (week 12, N=246; week 24, N=236) showed that increased service utilization was related to more severe bipolar disorder symptoms, physical side effects, and psychiatric and general medical comorbidities. Middle-aged individuals and those living in the United States longer tended to use more services than younger individuals or recent immigrants, respectively.

Conclusions  These data suggest that not all individuals with bipolar disorder seek treatment services at the same rate. Instead, specific clinical or demographic features may affect the degree to which one seeks treatment, conveying clinical and public health implications and highlighting the need for specific approaches to correct such discrepancies. Future research is needed to elucidate potential moderators of service utilization in bipolar disorder to ensure that those most in need of additional services utilize them.

Abstract Teaser
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Table 1Association between service use and clinical features of 246 outpatients with bipolar disordera
Table Footer Note

a Values were adjusted for visit effect.

Table Footer Note

b CGI-BP-S, Clinical Global Impression Scale for Bipolar Disorder Severity; MADRS, Montgomery-Åsberg Depression Rating Scale; YMRS, Young Mania Rating Scale; LIFE-RIFT, LIFE–Range of Impaired Functioning Tool. “Psychiatric comorbidities” refers to the number of lifetime comorbid diagnoses detected on the Extended Mini-International Neuropsychiatric Interview. High lipid profiles indicate low-density lipoprotein cholesterol >150 mg/dl. Fasting glucose was considered high at >100 mg/dl. Obesity was defined as a body mass index >30 kg/m2. Anxiety disorder was indicated for patients with a diagnosis of panic disorder, phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or generalized anxiety disorder.

Table Footer Note

c Remained significant in the multivariate analysis

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*p<.05, **p<.01

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Table 2Association of counseling service utilization and demographic features among outpatients with bipolar disordera
Table Footer Note

a A patient was defined as seeking therapy or counseling if he or she reported at week 12 on the Cornell Service Index seeing a psychologist, social worker, or other counselor.

Table Footer Note

b Determined with linear regression for continuous and ordinal categorical characteristics and logistic regression for unordered categorical characteristics. For unordered characteristics with more than two categories, the p value reflects a two-group comparison: for marital status, single and never married were compared with the remaining three; for education, no college was compared with some college; for employment, employed and student were compared with the remaining four catgories.

Anchor for Jump
Table 3Association of counseling service utilization and clinical features of 246 outpatients with bipolar disordera
Table Footer Note

a A patient was defined as seeking therapy or counseling if he or she reported at week 12 on the Cornell Service Index seeing a psychologist, social worker, or other counselor.

Table Footer Note

b CGI-BP-S, Clinical Global Impression Scale for Bipolar Disorder Severity; MADRS, Montgomery-Åsberg Depression Rating Scale; YMRS, Young Mania Rating Scale; LIFE-RIFT, LIFE–Range of Impaired Functioning Tool. Ranges shown are scores per group.

Table Footer Note

c The p values were determined with linear regression for continuous characteristics and logistic regression for unordered categorical characteristics.

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d Coded yes if the patient had a diagnosis of posttraumatic stress disorder, panic disorder, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, social phobia, or specific phobia.

Table Footer Note

e Coded yes if the patient met the threshold for any substance use disorder on the Structured Clinical Interview for DSM-IV.

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