Person:

Bauer, Mark

Background

Evidence suggests that patients with bipolar disorder have an elevated risk for comorbid posttraumatic stress disorder (PTSD) compared to those without a bipolar diagnosis. Although bipolar disorder is associated with decreased health-related quality of life (HRQOL), it is unclear whether comorbid PTSD interacts to affect HRQOL.

Method

Baseline data from a multi-site study of patients with bipolar disorder were analyzed. Patient surveys ascertained clinical and demographic information, including physical and mental HRQOL based on the SF-12, mood symptoms (PHQ-9, Internal State Scale), and self-reported co-occurring conditions including PTSD.

Results

Overall (N=384), 43.5% of patients self-reported co-occurring PTSD. Patients with PTSD had lower physical and mental HRQOL scores compared to those without PTSD (mean (SD) for those with and without PTSD, respectively): Mental Component Scale score 30.51 (8.22) and 32.86 (8.35); Physical Component Scale score 35.56 (7.77) and 37.21 (7.20). After adjusting for demographic and clinical factors including mood symptoms, multivariable linear regression analyses revealed that PTSD was no longer significantly associated with physical or mental HRQOL; however, depressive symptoms were independently associated with mental HRQOL (Beta −0.63, p<0.01).

Conclusion

Depressive symptoms may explain the association between PTSD and mental HRQOL. Clinicians working with these patients will want to emphasize treatment of depression as important towards improving HRQOL for this group.

Objectives

The goal of this randomized controlled pilot study was to determine whether Life Goals Collaborative Care (LGCC) compared to enhanced treatment as usual, reduced cardiometabolic factors and improved outcomes for persons with bipolar disorder from community-based practices.

Methods

Persons were randomized to receive LGCC (N=32) or enhanced treatment as usual (N=33). LGCC included four weekly self-management sessions and telephone contacts to encourage provider engagement and measurement-based care; enhanced treatment as usual included wellness mailings. Outcomes were body mass index-BMI, blood pressure, quality of life, functioning, and symptoms.

Results

Compared to enhanced treatment as usual, LGCC was not associated with reduced cardiometabolic risk factors based on 6 and 12-month repeated measures analyses. Among patients with BMI >=30 or systolic blood pressure >=140, LGCC was associated with decreased impaired functioning (respectively beta=−2.2, beta=−3.8;p=.04 for both) and depressive symptom scores (respectively beta=−2.0, beta=−3.5;both p=.04).

Conclusions

LGCC may improve outcomes among patients with elevated baseline cardiometabolic risk from community-based practices.

Objective

We implemented a set of processes of care measures for bipolar disorder that reflect psychosocial, patient preference, and continuum of care approaches to mental health, and examined whether veterans with bipolar disorder receive care concordant with these practices.

Method

Data from medical record reviews were used to assess key processes of care for 433 VA mental health outpatients with bipolar disorder. Both composite and individual processes of care measures were operationalized.

Results

Based on composite measures, 17% had documented assessment of psychiatric symptoms (e.g., psychotic, hallucinatory), 28% had documented patient treatment preferences (e.g., reasons for treatment discontinuation), 56% had documented substance abuse and psychiatric comorbidity assessment, and 62% had documentation of adequate cardiometabolic assessment. No-show visits were followed up 20% of the time and monitoring of weight gain was noted in only 54% of the patient charts. In multivariate analyses, history of homelessness (OR=1.61; 95% CI=1.05-2.46) and nonwhite race (OR=1.74; 95%CI=1.02-2.98) were associated with documentation of psychiatric symptoms and comorbidities, respectively.

Conclusions

Only half of patients diagnosed with bipolar disorder received care in accordance with clinical practice guidelines. High quality treatment of bipolar disorder includes not only adherence to treatment guidelines but also patient-centered care processes.

Background

We determined whether application of a novel implementation intervention (Enhanced Replicating Effective Programs-REP) versus its standard, dissemination-focused version (REP) improved fidelity to bipolar disorder treatment (Life Goals Collaborative Care- LGCC).

Methods

Five community practices from Michigan and Colorado were randomized to receive LGCC using Enhanced or standard REP. One provider at each practice implemented LGCC which included patient self-management support (4 group sessions focused on symptoms and behavior goals), guideline dissemination to providers, and ongoing phone care management focused on maintaining behavior goals and provider engagement. Standard REP included intervention packaging (i.e., translation of LGCC core components into user-friendly language), training, and as-needed technical assistance. Enhanced REP added customization of LGCC and ongoing, proactive technical assistance through an internal and external facilitator that focused on enhancing provider buy-in and uptake. Multiple and logistic regression analyses determined the impact on patient-level LGCC fidelity between Enhanced versus standard REP.

Results

Participants (N=384; mean age = 42 years, 67% women, 29% nonwhite) averaged 3.0 out of 4 LGCC group sessions and had 4.0 care management contacts. Enhanced REP implementation was associated with 2.6 (p<.001) greater total number of sessions/contacts than standard REP, which was driven by 2.5 (p<.01) more care management contacts, after adjusting for patient factors. Women and those with a history of homelessness received fewer sessions.

Conclusions

Enhanced REP implementation was associated with improved LGCC fidelity, primarily for care management contacts. Additional customization of interventions such as LGCC may be needed to ensure adequate treatment fidelity for key vulnerable populations.

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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 healthy 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.

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims under healthcare reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

Background: The movement of evidence-based practices (EBPs) into routine clinical usage is not spontaneous, but requires focused efforts. The field of implementation science has developed to facilitate the spread of EBPs, including both psychosocial and medical interventions for mental and physical health concerns. Discussion The authors aim to introduce implementation science principles to non-specialist investigators, administrators, and policymakers seeking to become familiar with this emerging field. This introduction is based on published literature and the authors’ experience as researchers in the field, as well as extensive service as implementation science grant reviewers. Implementation science is “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services.” Implementation science is distinct from, but shares characteristics with, both quality improvement and dissemination methods. Implementation studies can be either assess naturalistic variability or measure change in response to planned intervention. Implementation studies typically employ mixed quantitative-qualitative designs, identifying factors that impact uptake across multiple levels, including patient, provider, clinic, facility, organization, and often the broader community and policy environment. Accordingly, implementation science requires a solid grounding in theory and the involvement of trans-disciplinary research teams. Summary The business case for implementation science is clear: As healthcare systems work under increasingly dynamic and resource-constrained conditions, evidence-based strategies are essential in order to ensure that research investments maximize healthcare value and improve public health. Implementation science plays a critical role in supporting these efforts.

Introduction

Bipolar disorder is associated with functional impairment across a number of domains, including health-related quality of life (HRQOL). Many patients are treated exclusively in primary care (PC) settings, yet little is known how HRQOL outcomes compare between PC and community mental health (CMH) settings. This study aimed to explore the correlates of HRQOL across treatment settings using baseline data from a multisite, randomized controlled trial for adults with bipolar disorder.

Methods

HRQOL was measured using the SF-12 physical (PCS) and mental (MCS) health scales. Independent sample t-tests were calculated to compare differences in HRQOL between settings. Multivariate regression models then examined the effect of treatment setting on HRQOL, adjusting for covariate demographic factors, mood symptoms (Internal State Scale), hazardous drinking (AUDIT-C), and substance abuse.

Results

A total of 384 enrolled participants completed baseline surveys. MCS and PCS scores reflected similar impairment in HRQOL across PC and CMH settings (p = .98 and p = .49, respectively). Depressive symptoms were associated with lower MCS scores (B = −.68, p < .001) while arthritis/chronic pain was strongly related to lower PCS scores (B = −5.23, p < .001).

Limitations

This study lacked a formal diagnostic interview, relied on cross-sectional self-report, and sampled from a small number of sites in two states.

Discussion

Participants reported similar impairments in both mental and physical HRQOL in PC and CMH treatment settings, emphasizing the need for integrated care for patients with bipolar disorder regardless of where they present for treatment.