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									Economic Grand Rounds

The Economic Burden
of Bipolar Disorder
Glen L. Stimmel, Pharm.D., B.C.P.P.




B    ipolar disorder has a clear eco-
     nomic impact on patients with
the disorder, their families, care-
                                               ologic Catchment Area study found
                                               that the mean ages of onset for bipolar
                                               I and II disorders were approximately
                                                                                            prevalent cases, the lifetime estimate
                                                                                            cost model by Begley and colleagues
                                                                                            for incident cases is appropriate for
givers, and society as a whole. In ad-         18 and 22 years, respectively (4).           evaluating potential cost savings from a
dition, the prevalence of bipolar dis-            Regardless of age of onset, there is      reduction in the disease incidence rate
order may be underestimated, and               typically a five- to ten-year delay be-      or an improvement in the long-term
the treatment is often inappropriate.          tween onset and time of first treat-         disease maintenance. In the study by
Inadequate treatment is likely to in-          ment or first hospitalization (5). Peo-      Begley and colleagues, average lifetime
crease the cost of care, as well as the        ple with bipolar disorder usually see        cost per case ranged from $11,720 for
burden of illness on the individual,           several doctors and, on average,             persons with a single manic episode to
families, and caregivers.                      spend more than eight years seeking          $624,785 for persons with nonrespon-
                                               treatment before receiving a correct         sive or chronic episodes. In the Wyatt
Prevalence of bipolar                          diagnosis (6), which is likely to further    and Henter study, direct costs totaling
spectrum disorder                              influence outcome, as well as account        $7 billion consisted of expenditures for
Prevalence rates for bipolar disorder          for notable economic impact.                 treatment-related inpatient and outpa-
have been generally acknowledged to               Once bipolar disorder is diagnosed,       tient care, as well as non–treatment-re-
approximate 1 to 2 percent (1,2). These        actual treatment often falls far short       lated costs, such as use of the criminal
estimates likely fall on the conservative      of established treatment guidelines.         justice system. The $38 billion in indi-
side and may overlook the full spec-           In an evaluation of hospitalized pa-         rect costs from the Wyatt and Henter
trum of bipolar disorder. In particular,       tients with bipolar disorder, only one       study included the lost productivity of
the “softer” symptoms of bipolar disor-        in six patients discharged were receiv-      wage earners, totaling $17 billion;
der, which are not as easily recognized        ing medications that were consistent         homemakers, $3 billion; and care-
because of their less blatant features,        with national treatment guidelines           givers, $6 billion, as well as the cost of
may lead to a misdiagnosis of unipolar         (7). In a recent study of outpatients        institutionalization, $3 billion, and the
depression, among other syndromes.             with bipolar disorder, more than one-        lost productivity costs for individuals
Bipolar spectrum disorder may be de-           third of the patients were not receiv-       lost to suicide, $8 billion.
scribed as a longitudinal diagnosis that       ing any mood stabilizers (8). An                Providing close daily contact and
involves mood swings between states,           analysis of 3,349 patients with bipolar      care to patients with bipolar disorder
such as mania, hypomania, mixed                disorder in California’s Medicaid            exacts a toll on their families and
states, major depressive disorder, and         (Medi-Cal) program from 1994 to              caregivers. Many patients with bipo-
depressive states (1). If the full spec-       1998 found that 58 percent never re-         lar disorder divorce or experience
trum of bipolar disorders were ac-             ceived a mood stabilizer in the year         marital problems. Not only must
counted for, investigators assert that         following their diagnosis of bipolar         caregivers of patients with bipolar
the prevalence rate may be as high as          disorder. Direct health care costs           disorder deal with the impact of pa-
7 percent (3).                                 were significantly higher among pa-          tients’ symptoms, caregivers also feel
                                               tients who delayed taking or who did         the effects of patients’ illness on their
The economic impact                            not use mood-stabilizing agents dur-         work and leisure time. The combina-
of bipolar disorder                            ing the first year of their diagnosis (9).   tion of missed work hours and lower
The onset of bipolar disorder often oc-           The economic burden of bipolar dis-       productivity caused by stress adds a
curs in what should be a particularly          order in the United States is substan-       financial burden on the caregiver, as
productive time of life. The Epidemi-          tial. Using a lifetime cost simulation       well as on society as a whole.
                                               model, Begley and colleagues (10) de-           Bipolar disorder is the sixth leading
                                               termined that the lifetime cost for per-     cause of disability worldwide (12). Pa-
Dr. Stimmel is affiliated with the Univer-
sity of Southern California School of          sons with bipolar disorder was $24 bil-      tients with bipolar disorder and their
Pharmacy, 1985 Zonal Avenue, Los Ange-         lion in 1998, whereas Wyatt and Hen-         families experience significant losses
les, California 90089-9121 (e-mail, stim-      ter (11) calculated a cost of $45 billion    in functional status and quality of life,
mel@hsc.usc.edu). Steven S. Sharfstein,        in a 1991 sample. Unlike cost studies        placing untoward stress on personal
M.D., is the editor of the column.             that determine the annual cost for           relationships. Loss of employment,
PSYCHIATRIC SERVICES   ♦ http://ps.psychiatryonline.org ♦ February 2004 Vol. 55 No. 2                                             117
difficulty in regaining employment,         ment of bipolar disorders in children          References
days lost from work, and the potential      and adolescents could reduce the risk           1. Hirschfeld RM: Bipolar spectrum disorder:
for increased interactions with the         of subsequent substance abuse.                     improving its recognition and diagnosis.
                                                                                               Journal of Clinical Psychiatry 62(suppl 14):
criminal justice system all contribute         Patients with bipolar disorder fre-             5–9, 2001
not only to the cost but also to the dis-   quently suffer from a range of comor-
                                                                                            2. Zarate CA, Jr, Tohen M, Land M, et al:
ability associated with bipolar disorder.   bid psychiatric disorders aside from               Functional impairment and cognition in
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substantial number of patients still        disorder is higher than that of the
                                                                                            5. Sachs GS, Printz DJ, Kahn DA, et al: The
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for this are not clear.                     disorders (16).                                    Postgraduate Medicine 108(special no):1–
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ment may be even greater for patients       Conclusions                                     6. Ghaemi SN, Sachs GS, Chiou AM, et al: Is
                                                                                               bipolar disorder still underdiagnosed? Are
with bipolar disorder and comorbid          Bipolar disorder clearly has far-reach-            antidepressants overutilized? Journal of Af-
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are at greater risk for intrapsychic and    individual, families, caregivers, and           7. Lim PZ, Tunis SL, Edell WS, et al: Med-
psychosocial stress, which may pre-         society as a whole. There is increasing            ication prescribing patterns for patients
cipitate or exacerbate mood swings.         awareness that prevalence rates are                with bipolar I disorder in hospital settings:
                                                                                               adherence to published practice guidelines.
In addition, these patients typically       likely to be higher than previously be-            Bipolar Disorders 3:165–173, 2001
have greater symptom burden and             lieved and that the impact of bipolar
                                                                                            8. Blanco C, Laje G, Olfson M, et al: Trends
lower recovery rates (13).                  disorder may be far greater than en-               in the treatment of bipolar disorder by out-
   Patients with bipolar disorder and       visaged in the past. Increased preci-              patient psychiatrists. American Journal of
comorbid substance abuse place addi-        sion in diagnosing bipolar disorder is             Psychiatry 159:1005–1010, 2002
tional stresses on the health care sys-     needed, as well as increased attention          9. Li J, McCombs JS, Stimmel GL: Cost of
tem, because they commonly experi-          to ensuring that the treatment that is             treating bipolar disorder in the California
                                                                                               Medicaid (Medi-Cal) program. Journal of
ence fewer remissions and poorer out-       initiated and continued is consistent              Affective Disorders 71:131–139, 2002
comes than non-substance abusers.           with established treatment guidelines.
                                                                                           10. Begley CE, Annegers JF, Swann AC, et al:
Bipolar disorder with comorbid sub-            The ramifications of bipolar disor-             The lifetime cost of bipolar disorder in the
stance abuse is also associated with        der include a significant economic                 US: an estimate for new cases in 1998.
higher rates of refractoriness to lithi-    toll, as well as family disruption, care-          Pharmacoeconomics 19:483–495, 2001
um treatment (14) and higher risks of       giver stress, and an individual burden         11. Wyatt RJ, Henter I: An economic evalua-
suicide attempts and completions (13).      encompassing comorbid illnesses,                   tion of manic-depressive illness—1991. So-
                                                                                               cial psychiatry and psychiatric epidemiolo-
   Data from the Epidemiologic              substance abuse, poor functionality,               gy 30:213–219, 1995
Catchment Area study (15) demon-            and high suicide risk. Studies have            12. Woods SW: The economic burden of bipo-
strated that substance abuse or de-         found that years elapse before pa-                 lar disease. Journal of Clinical Psychiatry
pendence is more frequently diag-           tients are correctly diagnosed, and in-            61(suppl 13):38–41, 2000
nosed among persons with bipolar dis-       adequate treatment is likely to in-            13. Practice guideline for the treatment of pa-
order than among persons with any           crease the illness burden and cost of              tients with bipolar disorder (revision).
                                                                                               American Journal of Psychiatry 159(suppl
other axis I disorder. The study found      care. Under these circumstances, cli-              4):1–50, 2002
that approximately 56 percent of pa-        nicians are obligated to be wary of the
                                                                                           14. Goldberg JF, Garno JL, Leon AC, et al: A
tients with bipolar I and II disorder       possible missed diagnosis of bipolar               history of substance abuse complicates re-
abused or were dependent on drugs,          disorder. It is also important that cli-           mission from acute mania in bipolar disor-
and approximately 44 percent had co-        nicians maintain an awareness of at-               der. Journal of Clinical Psychiatry 60:733–
                                                                                               740, 1999
morbid alcohol abuse. Lifetime preva-       tendant comorbid illnesses and the
lence rates of substance abuse among        risk of suicide in these patients. Final-      15. Regier DA, Farmer ME, Rae DS, et al: Co-
                                                                                               morbidity of mental disorders with alcohol
persons with bipolar I disorder are         ly, adequate and individualized treat-             and other drug abuse: results from the Epi-
more than three times those seen in         ment is paramount in lessening the                 demiologic Catchment Area (ECA) Study.
the general population, whereas pa-         burden of illness experienced.                     JAMA 264:2511–2518, 1990
tients with bipolar II are more than                                                       16. Oquendo MA, Waternaux C, Brodsky B, et
twice as likely to abuse substances         Acknowledgment                                     al: Suicidal behavior in bipolar mood disor-
                                                                                               der: clinical characteristics of attempters
than patients with unipolar depres-         This work was supported by an unrestrict-          and nonattempters. Journal of Affective
sion. Earlier recognition and treat-        ed grant from GlaxoSmithKline.                     Disorders 59:107–117, 2000

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