Three key data for delays in the diagnosis and treatment of bipolar disorder

Medical Pulse Guide

Previous studies investigating delays in the diagnosis and treatment of bipolar disorder have been numerous but highly heterogeneous, which has interfered with the interpretation of results
.
What stands out in particular is that different studies define "diagnosis and treatment" differently
.

In this systematic review and meta-analysis of 59 studies and more than 40,000 patients, the median duration of "delayed help", "delayed diagnosis", and "delayed treatment" in bipolar disorder was 3.
5 years, 6.
7 years, and 5.
9 years
, respectively.

When bipolar disorder is not recognized and treated, the cost per patient is about US$ 100 per month
.
A more consistent definition of the components of delayed diagnosis and treatment of bipolar disorder and better quality and targeted studies
are needed in the future.

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More and more evidence shows that the diagnosis and treatment of mental illness cannot be delayed, "time is function", "time is neuron"
.
In addition to schizophrenia spectrum disorder, delays in diagnosis and treatment of bipolar disorder (BD) have been extensively studied
.

However, the number of previous studies investigating delays in the diagnosis and treatment of bipolar disorder has been high in terms of heterogeneity, which interferes with the interpretation of the results
.
What stands out in particular is that different studies define "diagnosis and treatment" differently, and the first help, obtaining a diagnosis, obtaining any treatment, obtaining evidence-based treatment, etc.
are all considered forms of
diagnosis and treatment.
It is necessary to discuss different definitions of diagnosis and treatment on the basis of excluded case series studies, small sample size studies, and studies for special populations, so as to obtain more specific and more granular results
.

Brief introduction to the study

In a systematic review and meta-analysis published online on 26 August in Acta Psychiatr Scand.
, Jan Scott et al.
of Newcastle University reviewed the literature published between January 2000 and July 2022 on delays in the diagnosis and treatment of bipolar disorder, and discussed
the delay in diagnosis and treatment into "delay in help" (DHS), "delay in diagnosis" (DD), and "delay in treatment" (DUB).

Based on a range of inclusion criteria (e.
g.
, target sample size ≥50), researchers selected 59 studies from 1,074 publications, with 54% European studies representing more than 40,000 patients
.
The main findings are as follows:

Delay in asking for help

Defined as the length of time between the onset of any mood symptoms and the seeking of formal help, where "formal help" includes a visit to a GP, psychologist or psychiatrist
.

Pooled analysis of 2256 patients from eight studies showed a weighted mean delay in seeking help in people with bipolar disorder of 5.
01 years (95% CI: 2.
65, 7.
37) and a median of approximately 3.
5 years (IQR: 2.
8, 8.
48); Study heterogeneity was high (^I2=74%) and there was no evidence of
publication bias.

Diagnostic delay

Defined as the time
between the onset of any mood episode (depression, hypomania, mania, with or without psychotic symptoms) and the diagnosis of bipolar disorder, schizoaffective disorder, affective psychosis.

Pooled analysis of 3035 patients in 20 studies showed a weighted mean delay in diagnosis of patients with bipolar disorder of 7.
20 years (95% CI: 5.
69, 8.
72) and a median of 6.
7 years (IQR: 5.
6, 8.
9); Study heterogeneity was low (^I2 = 27%) and there was no evidence
of publication bias.

Female (compared with male, p=0.
036), outpatient (compared with hospitalization, p=0.
002), North America (compared with Europe, p=0.
03) patients had a longer
delay in diagnosis.
Patients with bipolar I disorder had a shorter delay in diagnosis (p=0.
005).

Delay in treatment

Defined as the time
between diagnosis of bipolar disorder, schizoaffective disorder, affective psychosis, and initiation of guideline-recommended treatment (mood stabilizers and/or antipsychotics, outpatient or hospitalized).

Pooled analysis of 14,389 patients from 45 studies showed a weighted mean delay in treatment of 5.
17 years (95% CI: 3.
95 to 6.
39) and a median of 5.
9 years (IQR: 1.
1, 8.
2) for patients with bipolar disorder; Heterogeneity was high in all 45 studies (I2=64%), heterogeneity after excluding studies of early intervention in psychiatric disorders was low (^I2=31%), and publication bias was close to statistically significant (p=0.
06).

Female (p=0.
036) and early onset (p=0.
015) had a longer
delay in treatment.
There was a significant interaction between gender and diagnosis: women with non-bipolar I disorder had a longer delay in treatment (p=0.
031).

Patients from outpatient clinics had a longer delay in treatment than patients from ward and early intervention outpatient settings (p=0.
03).

Patients with psychotic symptoms (p=0.
01) or manic episodes (p=0.
044) had a shorter
delay in treatment.

Women with bipolar disorder are more likely to seek formal help than men, but there is a greater delay in diagnosis and treatment
.
For example, some young women with bipolar disorder are misdiagnosed with borderline personality disorder
.

conclusion

It is generally believed that the peak incidence of bipolar disorder is 15-25 years old; However, a significant number of patients do not receive diagnosis and formal treatment
recommended by guidelines until the age of 25 to 35 years.
In contrast, patients who have access to early intervention services are expected to be on the right track earlier, but the number of these patients is not large
.

Intuitively, diagnosis may not seem far from evidence-based treatment, but in this analysis, the delay between diagnosis and guideline-recommended treatment in patients with bipolar disorder was 5.
9 years, possibly due to non-evidence-based
treatment.
The authors mention that age 30 appears to be a key time point for prescribing mood stabilisers, and the likelihood of prescribing mood stabilisers clinically to patients under 30 years of age appears to be lower
.

Looking at each link of the delay in diagnosis and treatment of bipolar disorder separately, the delay in diagnosis seems to be the most prominent problem.
As we all know, the identification of monopolar and bipolar depression is a high-frequency topic
that cannot be bypassed by psychiatric clinics.
The data shows that when bipolar disorder is not identified and treated, the cost per patient per month is about $100
.
A more consistent definition of the components of delayed diagnosis and treatment of bipolar disorder and better quality and targeted studies
are needed in the future.

Bibliographic index: Scott J, Graham A, Yung A, Morgan C, Bellivier F, Etain B.
A systematic review and meta-analysis of delayed help-seeking, delayed diagnosis and duration of untreated illness in bipolar disorders.
Acta Psychiatr Scand.
2022 Aug 26.
doi: 10.
1111/acps.
13490.
Epub ahead of print.
PMID: 36018259.