Busch Alisa B, Huskamp Haiden A, Landrum Mary Beth
Alcohol and Drug Abuse Treatment Program, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA.
Psychiatr Serv. 2007 Jun;58(6):848-54. doi: 10.1176/ps.2007.58.6.848.
This study examined whether presenting diagnosis and treatment in intensive settings (hospitalization, partial hospitalization, or residential programs) are correlated with the subsequent treatment of bipolar I disorder.
Claims data were studied retrospectively (fiscal years 1994-2000) for 2,644 patients with bipolar I disorder who had been enrolled in Medicaid at least six months before their first observed bipolar diagnosis. Logistic regression models estimated the association between the presenting diagnosis and initial treatment setting and the subsequent treatment up to one year after the first observed bipolar diagnosis. Measures included receipt of guideline-recommended care (antimanic agent plus psychotherapy) or care discouraged by guidelines (an antidepressant without an antimanic agent).
Only one-third of enrollees received both guideline-recommended treatments after the first observed bipolar diagnosis. Patients were less likely to receive both recommended treatments if the first observed mental health service occurred in an intensive setting. Enrollees presenting with a bipolar diagnosis were less likely to receive psychotherapy, whereas rates of antimanic medication use were similar to those with other presenting diagnoses. Presenting with depression or anxiety or other, nonbipolar diagnoses was associated with a higher likelihood of receiving pharmacotherapy discouraged by guidelines.
This study raises general concerns for the treatment quality of bipolar I disorder in this medically complicated, largely disabled Medicaid population. Also, how bipolar I patients enter treatment can be associated with subsequent differences in treatment quality--information that can be useful to clinicians and policy makers when planning quality improvements to treatment programs.
本研究探讨在强化治疗环境（住院治疗、部分住院治疗或住院项目）中进行诊断和治疗是否与双相I型障碍的后续治疗相关。
对2644例双相I型障碍患者的索赔数据进行回顾性研究（1994 - 2000财政年度），这些患者在首次观察到双相诊断前至少已参加医疗补助计划六个月。逻辑回归模型估计首次观察到双相诊断时的诊断和初始治疗环境与首次观察到双相诊断后长达一年的后续治疗之间的关联。测量指标包括接受指南推荐的治疗（抗躁狂药物加心理治疗）或指南不鼓励的治疗（无抗躁狂药物的抗抑郁药物）。
在首次观察到双相诊断后，只有三分之一的登记者接受了两种指南推荐的治疗。如果首次观察到的心理健康服务是在强化治疗环境中进行的，患者接受两种推荐治疗的可能性较小。首次诊断为双相障碍的登记者接受心理治疗的可能性较小，而使用抗躁狂药物的比例与其他诊断的患者相似。出现抑郁、焦虑或其他非双相诊断与接受指南不鼓励的药物治疗的可能性较高相关。
本研究引发了对这一医疗复杂、大多残疾的医疗补助人群中双相I型障碍治疗质量的普遍关注。此外，双相I型患者开始治疗的方式可能与后续治疗质量的差异相关——这一信息对临床医生和政策制定者在规划提高治疗项目质量时可能有用。
