Abstract
Objective
To compare the risk of hospitalization for adult Medicaid beneficiaries with bipolar I disorder treated with lurasidone vs. other oral atypical antipsychotics (AAPs) as monotherapy.
Methods
A retrospective cohort study of the IBM MarketScan Multi-State Medicaid Claims database identified adults with bipolar I disorder who initiated an AAP (index date) between 1 January 2014 and 30 June 2019. Patients were continuously enrolled 12 months pre- and 24 months post-index date. Each month during the post-index period was categorized as monotherapy with lurasidone, aripiprazole, olanzapine, quetiapine or risperidone, no/minimal treatment, or other. Marginal structural models were performed to estimate hospitalization risk and length of stay (LOS) (all-cause and bipolar I disorder-related) compared to lurasidone.
Results
The analysis included 8262 adults. Compared to lurasidone, the adjusted odds ratios (aORs) of all-cause hospitalization were significantly higher for olanzapine (aOR = 1.60, 95% CI = 1.09–2.10) and quetiapine (aOR = 1.54, 95% CI = 1.18–1.89). The risk was significantly higher for bipolar I disorder-related hospitalization for quetiapine (aOR = 1.57, 95% CI = 1.10–2.04) and risperidone (aOR = 1.80, 95% CI = 1.04–2.56) compared to lurasidone. The bipolar I disorder-related LOS per 100 patient-months was more than twice as long for quetiapine (8.42 days) compared to lurasidone (3.97 days, p < .01).
Conclusions
Lurasidone-treated adult Medicaid patients with bipolar I disorder had significantly lower risk of all-cause hospitalization than those treated with olanzapine and quetiapine and lower risk of bipolar I disorder-related hospitalization than quetiapine and risperidone. Bipolar I disorder-related hospital LOS was significantly shorter for patients treated with lurasidone compared to quetiapine.
Introduction
Bipolar disorder is a psychiatric mood disorder characterized by recurrent episodes of depression and mood elevation (mania or hypomania)Citation1 with an annual prevalence of approximately 2.8% among adults in the USCitation2,Citation3. Depressive symptoms are more frequent than mood elevation or mixed symptoms with 34.1% of time spent in depressive episodes versus 12.3% in manic or mixed episodesCitation4. Patients experiencing a depressive episode have a higher risk of attempting suicide than patients with mood elevationCitation5,Citation6.
Bipolar disorder is associated with a substantial economic burden worldwide. In the US, annual costs are estimated at more than $195 billion, of which approximately 20% is attributed to direct medical costsCitation7. Over 40% of excess medical costs for patients with bipolar I disorder vs. patients without bipolar disorder in the US are due to inpatient hospital useCitation8. Additionally, patients with bipolar disorder experience higher rates of comorbidities including cardiometabolic conditions such as metabolic disorders, obesity and diabetes, as well as psychiatric conditions such as anxiety and substance use disorderCitation6. Psychiatric and cardiometabolic comorbidities are associated with higher all-cause and psychiatric hospitalizations and longer hospital length of stay among patients with bipolar disorderCitation9,Citation10.
Pharmacologic treatment recommendations for bipolar disorder vary by illness phase (mania or hypomania, depression, maintenance) but generally include mood stabilizers and antipsychotic medicationsCitation11. Lithium, a mood stabilizer, is a first-line treatment for the management of acute mania and for long-term maintenance, and evidence also supports the use of lithium in patients with bipolar depressionCitation11. Atypical antipsychotics (AAPs) are used by 45% to 61% of patients with bipolar I disorder in the USCitation12. A number of AAPs have been approved by the US Food and Drug Administration (FDA) for the management of mania and maintenance therapy (e.g. aripiprazole, olanzapine, quetiapine, risperidone), whereas only four agents are currently approved by the FDA for the management of acute episodes of depression in patients with bipolar disorder: lurasidone, quetiapine, cariprazine and olanzapine–fluoxetineCitation6. Most patients (88.7%–96.2%) start bipolar I disorder treatment with monotherapy, but after initial treatment up to 70% are treated concomitantly with other medications including mood stabilizersCitation12. Lurasidone is the only AAP that is approved as an adjunctive treatment with lithium or valproate for bipolar depressionCitation6.
Medicaid plays a key role in covering and financing behavioral health care in the USCitation13. In 2015, Medicaid covered 14% of the general adult population but 21% of adults with mental illnessCitation13. Treatment costs for mental illness are high and have become burdensome for state Medicaid programs and managed care organizationsCitation14,Citation15. The average annual cost for an adult Medicaid patient with bipolar disorder was $16,038 (2015 US dollars), of which the primary cost driver is inpatient care (35%) followed by outpatient services (16%), prescriptions (13%), physician visits (11%), other medical services (11%), mental health services (8%), emergency room visits (6%) and laboratory tests (<1%)Citation15,Citation16.
Several studies have evaluated healthcare resource use associated with oral AAPs for the treatment of bipolar disorderCitation17–19. However, no studies have examined healthcare resource use of lurasidone vs. other oral AAPs among patients with bipolar disorder in a Medicaid population. The objective of this study was to compare the risk of hospitalization among adults with bipolar I disorder when treated with lurasidone compared to other AAPs as monotherapy over a 24 month follow-up period in a Medicaid population.
Methods
Data source
A retrospective database analysis was conducted using data from the IBM MarketScan Multi-State Medicaid Database (MarketScan) (IBM, Somers, NY, USA) from 1 January 2014 to 30 June 2019. The MarketScan data covers over 44 million Medicaid enrollees from 11 geographically dispersed states and includes complete medical, outpatient pharmacy and enrollment data. The data were extracted in compliance with the Health Insurance Portability and Accountability Act of 1996Citation20. As such, this study did not require institutional review board (IRB) approval.
Patient inclusion/exclusion criteria
Patients with bipolar I disorder were eligible for inclusion in the analysis if they initiated an oral AAP (asenapine, aripiprazole, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, quetiapine (both extended release and immediate release), olanzapine, paliperidone, risperidone or ziprasidone) as monotherapy during the study period. Initiation of an oral AAP treatment was defined as having no AAP use in the 12 months prior to the first observed fill of the oral AAP. Monotherapy treatment was defined as ≥24 days of oral AAP treatment during the month (i.e. 80% of days) without concurrent treatment (≤7 days’ supply) with other oral AAPs or mood stabilizers. The date of the first monotherapy oral AAP prescription fill was defined as the index date. Patients with bipolar I disorder were identified by diagnosis code (International Classification of Diseases, 9th revision, Clinical Modifications [ICD-9-CM]: 296.0X, 296.1X, 296.4X, 296.5X, 296.6X, 296.7X, 296.80, 296.81; 10th revision [ICD-10-CM]: F30.XX, F31.0, F31.1X, F31.2, F31.3X, F31.4, F31.5, F31.6X, F31.7X, F31.89, F31.9) during the 12 months prior to or on the index date. Consistent with previous analyses of the MarketScan data, a diagnosis of bipolar I disorder was based on at least one inpatient claim or two outpatient claimsCitation19. Patients were required to be adults (age at first oral AAP fill ≥18 years) and to be continuously enrolled in the health plan for 12 months prior to the index date (pre-index period) and 24 months after the index date (post-index period) to ensure no lapses in coverage.
Patients were excluded from the analysis if they had a diagnosis of schizophrenia (ICD-9-CM: 295.X; ICD-10-CM: F20.X) during the study period; used long-acting injectable AAPs (LAIs) such as LAI formulations of aripiprazole (HCPCS: J1942, C9470, J0400, J0401), olanzapine (HCPCS: J2358), paliperidone (HCPCS: J2426), risperidone (HCPCS: J2794, S0163, C9125, C9037) or ziprasidone (HCPCS: J3486, C9204); or were pregnant (ICD-9-CM: 630.xx–679.xx; ICD-10-CM: O00.xx–O9x.xx) during the study period.
Oral atypical antipsychotic monotherapy treatment categories
The primary treatments of interest were monotherapy oral AAPs. Because treatment can change over time, patients were assigned to treatment groups in 30 day intervals (“months”) during the 24-month follow-up period. The patient treatment-month, therefore, was the primary unit of analysis in the study. Patients treated with oral AAPs were classified as receiving lurasidone monotherapy, aripiprazole monotherapy, olanzapine monotherapy, quetiapine monotherapy, risperidone monotherapy or other treatment. Monotherapy treatment was defined as ≥24 days of oral AAP treatment during the month (i.e. 80% of days) without concurrent treatment (≤7 days’ supply) with other oral AAPs or mood stabilizers. All patients were treated with oral AAP monotherapy during the index month. After the index month, patients that either filled 8–23 days of AAP or switched to concomitant therapy were included in the “other treatment” category. The other treatment category included other oral AAPs used as monotherapy (asenapine, brexpiprazole, cariprazine, ziprasidone, iloperidone, paliperidone and clozapine) due to small sample size; treatment with multiple oral AAPs; 8–23 days’ supply of one or more oral AAPs; and treatment including ≥8 days’ supply of mood stabilizers. All other patients that received no treatment with oral AAPs or ≤7 days of any oral AAP therapy or mood stabilizer were classified as no/minimal treatment for the patient treatment-month. Patients that discontinued treatment with oral AAPs at each treatment month were included in the no/minimal treatment category for that month.
Inpatient healthcare resource utilization
The primary outcome of interest was inpatient healthcare resource utilization measured by the all-cause and bipolar I disorder-related (any phase) inpatient admission rate per 100 patient-months and hospital length of stay (LOS) per 100 patient-months. All-cause hospitalizations were defined as any inpatient hospital stay. Bipolar I disorder-related hospitalizations were defined as any inpatient hospital stay with a bipolar I disorder diagnosis in any diagnosis code field. Hospital LOS was calculated as the number of days between hospital admission and discharge including emergency department visits for patients directly admitted to an inpatient facility.
Demographics, comorbidities and other variables
Additional patient characteristics recorded from the data included demographics, comorbidities and other healthcare resource utilization variables. Demographic variables were recorded at the index date and included age, gender and race/ethnicity (white, black, Hispanic, other, missing). The Charlson comorbidity index (CCI) was calculated for the 12 month pre-index periodCitation21. Diagnoses of diabetes (ICD-9-CM: 250.0–250.7; ICD-10-CM: E10–E14), hyperlipidemia (ICD-9-CM: 272.0x–272.4x; ICD-10-CM: E78.0x–E78.4x, E78.5), hypertension (ICD-9-CM: 401.xx−405.xx, 437.2, 362.11; ICD-10-CM: H35.03x, I10.xx–I15.xx, I67.4, N26.2), obesity (ICD-9-CM: 278.0x, V85.3x, V85.4x; ICD-10-CM: E66.xx, Z68.3x, Z68.4x), and mental health disorders including anxiety, major depressive disorder (MDD), bipolar II disorder and substance abuse (alcohol, opioids, cannabis, cocaine, other stimulants) were recorded for the 12-month pre-index period (Supplementary Materials Table S1). The substance abuse indicators were also recorded monthly in the 24-month post-index period. Psychotropic medication use including antidepressants, anxiolytics and mood stabilizers were recorded for the 12 month pre-index period. Other healthcare resource utilization variables were calculated for both the 12 month pre-index period (inpatient admission rate and hospital LOS) and monthly in the 24 month post-index period (office visits).
Statistical methods
Frequency and percentages were reported for categorical variables, and mean and standard deviation (SD) were reported for continuous variables. Median and interquartile range (IQR) were reported for AAP dose. Significance compared to patients treated with lurasidone monotherapy at index month was tested with t-tests for continuous variables and pairwise tests of proportions for categorical variables.
To control for time-varying confounders (i.e. factors which affect both the outcomes of interest and current or future treatments) and treatment, marginal structural models (MSMs) were used to estimate the inpatient admissions rate and hospital LOSCitation22. The MSM design controls for treatment switching, which is frequent in patients receiving antipsychotics and complicates the estimation of the association of treatments with outcomes when using an ITT (intent-to-treat) approachCitation23. MSMs have been used in observational studies of mood disorders using healthcare administrative claims dataCitation19. The stabilized inverse probability of treatment weights (IPTW) was calculated for each month in the post-index period using predicted probabilities from multinomial logistic regressions for the seven treatment classifications (lurasidone as reference, aripiprazole, olanzapine, quetiapine, risperidone, no/minimal treatment and other treatment). All-cause and bipolar I disorder-related hospitalization rates were modeled with generalized linear models with a logit link and clustered by patient to estimate the adjusted odds ratios (aORs) and 95% confidence intervals (CIs). All-cause and bipolar I disorder-related hospital LOS were modeled with zero-inflated Poisson regression models to estimate the adjusted incidence rate ratios (aIRRs) and 95% CI. Time-invariant covariates included age, sex, race, the pre-index period CCI score, pre-index period comorbidities, the pre-index period dependent variable and index year. Time-varying covariates included the prior-period treatment category, the prior-period dependent variable, the prior-period office visits, the prior-period substance abuse indicators and a post-index month indicator. Additional details of the MSM estimation are available in the Supplementary materials. All models were assessed for goodness of fit, and no multiple testing adjustments were performed.
The analysis was conducted using SAS 9.4 (SAS Institute, Cary, NC, USA) and Stata 16 (StataCorp, College Station, TX, USA). Statistical significance was indicated for all analyses at p < .01 and p < .05. A sensitivity analysis was conducted for the length of time required on a specific oral AAP in the study definition of monotherapy. The required minimum number of days on the therapy was reduced to 22 days (from 24 days) within a month to be more comparable to earlier studies of oral AAP treatment in a commercially insured populationCitation19.
Results
Patient characteristics
After applying the study inclusion/exclusion criteria, the analysis included 8262 adult patients with bipolar I disorder at month 1 of the post-index period. shows the patient flow through the inclusion/exclusion criteria.
Figure 1. Patient inclusion flow chart.
Pre-index and month 1 patient characteristics are reported in . At month 1, patients were assigned to the following treatment groups: lurasidone monotherapy (13.9%), aripiprazole monotherapy (17.0%), olanzapine monotherapy (7.6%), quetiapine monotherapy (28.8%), risperidone monotherapy (10.2%) or other treatment (21.6%).
Table 1. Pre-index patient demographics, comorbidities and healthcare utilization by treatment group at index.
Patients initiating treatment on lurasidone monotherapy compared to other treatment groups were on average younger (lurasidone mean age = 38.2; vs. olanzapine = 39.4, p < .05; vs. quetiapine = 39.3, p < .01), had a higher proportion female (lurasidone = 77.8%; vs. olanzapine = 62.5%, p < .01; vs. quetiapine = 69.9%, p < .01; vs. risperidone = 69.1%, p < .01) and had a higher proportion white (lurasidone = 71.2%; vs. olanzapine = 64.4%, p < .01; vs. quetiapine = 62.4%, p < .01; vs. risperidone = 56.2%, p < .01).
In the pre-index period, patients initiating treatment on lurasidone monotherapy were more likely to have a history of anxiety vs. risperidone monotherapy (57.3% vs. 49.3%, p < .01) but a lower rate of substance abuse (lurasidone = 32.3%; vs. olanzapine = 44.0%, p < .01; vs. quetiapine = 39.6%, p < .01). A higher percentage of patients initiating treatment on lurasidone had also been diagnosed with obesity (lurasidone = 28.3%; vs. olanzapine = 14.2%, p < .01; vs. quetiapine = 21.6%, p < .01; vs. risperidone = 18.5%, p < .01) and diabetes (lurasidone = 17.6%; vs. olanzapine = 12.0%, p < .01; vs. quetiapine = 14.7%, p < .05).
During the follow-up period (month 2–month 24), 7964 treatment months were identified as lurasidone monotherapy, 9600 as aripiprazole, 3555 as olanzapine, 16,178 as quetiapine and 4461 as risperidone (). The patient distribution by treatment cohort over the 24 month post-index period is reported in Supplementary Materials Table S2. After the index month, 50% of patients treated with lurasidone discontinued the treatment during month 2 compared to 47% for aripiprazole, 53% for olanzapine, 49% for quetiapine and 56% for risperidone. The median daily dose was 40.0 mg (IQR = 36.0–74.7) for lurasidone, 10.0 mg (IQR = 5.0–15.0) for aripiprazole, 9.3 mg (IQR = 5.0–10.0) for olanzapine, 100.0 mg (IQR = 50.0–200.0) for quetiapine and 1.0 mg (IQR = 0.9–2.0) for risperidone (Supplementary Materials Table S3).
Table 2. Adjusted risk of all-cause and bipolar I disorder-related hospitalizations and hospital length of stay during 24-month follow-up period.
Marginal structural model
The marginal structural model adjusted results controlling for time-invariant and time-varying covariates during the 24 month follow-up period are shown in . The adjusted odds ratios for the hospitalization rate and the adjusted incidence rate ratios for hospital LOS are presented in and , respectively.
Figure 2. Marginal structural model adjusted risk of all-cause and bipolar I disorder-related hospitalizations during 24 month follow-up period. Abbreviations. CI, Confidence interval; OR, Odds ratio; ref, Reference. Bold text indicates statistical significance based on 95% CI.
Figure 3. Marginal structural model adjusted risk of all-cause and bipolar I disorder-related hospital length of stay during 24 month follow-up period. Abbreviations. CI, Confidence interval; IRR, Incidence rate ratio; ref, Reference. Bold text indicates statistical significance based on 95% CI.
After adjusting for time-invariant and time-varying covariates during the 24 month follow-up period, the all-cause hospitalization rate per 100 patient-months remained significantly lower for lurasidone vs. olanzapine (2.13 vs. 3.18, p < .05; aOR = 1.60, 95% CI = 1.09–2.10) and quetiapine (2.13 vs. 3.08, p < .01; aOR = 1.54, 95% CI = 1.18–1.89). The bipolar I disorder-related hospitalization rate remained significantly lower for lurasidone vs. quetiapine (0.93 vs. 1.41, p < .05; aOR = 1.57, 95% CI = 1.10–2.04). Additionally, the bipolar I disorder-related hospitalization rate, which was numerically lower in the unadjusted analysis, became statistically significantly lower for lurasidone vs. risperidone (0.93 vs. 1.59, p < .05; aOR = 1.80, 95% CI = 1.04–2.56) when adjusted for time-invariant and time-varying confounders in the MSM. The bipolar I disorder-related hospital LOS remained significantly shorter for lurasidone vs. quetiapine (4.0 days vs. 8.4 days, p < .01; aIRR = 2.12, 95% CI = 1.32–2.92).
The sensitivity analysis that reduced the required days on an oral AAP during the month from 24 days to 22 days did not change the conclusions of the study.
Discussion
This is the first study to compare real-world hospitalization rates among adult Medicaid patients with bipolar I disorder who initiated lurasidone vs. other oral AAPs as monotherapy. The results of this retrospective claims database analysis demonstrate that patients treated with lurasidone had significantly lower risks of all-cause and bipolar I disorder-related hospitalization than patients treated with quetiapine. Additionally, quetiapine-treated patients had significantly longer bipolar I disorder-related hospital LOS that was more than twice as long as for patients treated with lurasidone.
These results are consistent with findings from a prior study which compared the risk of all-cause and psychiatric hospitalization in commercially insured patients with bipolar disorder treated with lurasidone versus other oral AAPsCitation19. In the previous study, over a 12 month follow-up period, lurasidone-treated patients with bipolar disorder had a significantly lower risk of all-cause hospitalization compared to patients treated with aripiprazole, quetiapine, olanzapine and risperidone, and a significantly lower risk of psychiatric hospitalization versus quetiapine, olanzapine and risperidoneCitation19. In the current study, the risk of all-cause hospitalization over the 24 month follow-up period was significantly lower for lurasidone compared to quetiapine and olanzapine, and numerically lower for lurasidone versus risperidone and aripiprazole.
Reasons for the lower rates of hospitalizations among patients treated with lurasidone versus other oral AAPs in this study are not known but may be due, in part, to the better efficacy and tolerability of lurasidone compared to the other oral AAPs as reported from prior studies. A network meta-analysis (NMA) examined the efficacy and tolerability profile of lurasidone vs. other oral AAP monotherapy in patients with bipolar depression from 14 randomized clinical trialsCitation24. The NMA found that lurasidone was associated with higher odds of achieving response and remission compared to aripiprazole, olanzapine and quetiapineCitation24. A more recent NMA of pharmacological treatments for acute bipolar depression reported a greater standard mean difference (SMD) change in depression rating score for lurasidone vs. placebo compared to aripiprazole, cariprazine, olanzapine and quetiapineCitation25.
Lurasidone’s minimal impact on metabolic parameters was cited by the 2019–2020 Florida Best Practice Psychotherapeutic Medication Guidelines as a reason to recommend lurasidone over quetiapine as an initial treatment for bipolar depressionCitation26. A retrospective analysis of patients with bipolar disorder found a greater number of cardiometabolic comorbidities to be associated with an increased hospital LOSCitation9. Short-term and long-term treatment with lurasidone has been found to be associated with a relatively low risk for developing metabolic syndromeCitation27. Weight gain, which is associated with nonadherence among US patients with bipolar disorderCitation28, has been shown to be significantly lower for lurasidone compared to olanzapine (mean difference = −2.54 kg, 95% CI = −3.42 to −1.67) and quetiapine (mean difference = −0.83 kg, 95% CI = −1.59 to −0.08)Citation24. Other aspects of lurasidone’s safety profile including no QTc prolongation and negligible effects on prolactin also compare favorably to other atypical antipsychoticsCitation29.
Higher adherence to AAP treatment may also help to explain the lower hospitalization rates for lurasidone vs. other oral AAPsCitation30,Citation31. Using a different design from the current study, a real-world study of adult Medicaid patients with bipolar disorder found that patients treated with lurasidone monotherapy had greater adherence (medication possession ratio ≥ 80%) compared to other oral AAPs (aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone; all p < .05)Citation32.
In our analysis, patients treated with lurasidone had higher rates of antidepressant use in the pre-index period compared to olanzapine, quetiapine and risperidone. Though not directly comparable due to the study design, the rates of antidepressant use were not significantly different between treatment cohorts during the follow-up period (except aripiprazole). This drop in antidepressant use may indicate better control of depressive symptoms in patients treated with lurasidone (Supplementary Materials Table S4). More than half of treatment months for quetiapine were prescribed at a sub-therapeutic level (median 100 mg per day vs. 300–800 mg per day indicated for bipolar disorder) (Supplementary Materials Table S3). Re-analysis of the data excluding patients prescribed sub-therapeutic levels of quetiapine did not change the conclusions of the study. In fact, higher doses of quetiapine were associated with higher risk of hospitalization (not shown). Physicians may have prescribed lower doses of quetiapine to their patients to avoid treatment-emergent side-effects.
Bipolar disorder is a recurring condition that requires treatment over the patient’s lifetime. This study of the Medicaid population contributes to the literature on healthcare resource utilization outcomes and the use of oral AAPs for the treatment of bipolar disorder. The lower risk of hospitalization and shorter hospital LOS associated with lurasidone could help to reduce the economic burden of bipolar disorder on Medicaid programs.
There are several limitations to this study. First, administrative claims data are collected for billing, not research, purposes and may include coding errors and misclassifications. Second, this study was of adult US Medicaid patients with bipolar I disorder initiating treatment with AAP monotherapy. Therefore, the results may not be generalizable to other patient populations such as patients with non-Medicaid insurance, without health insurance or patients who are already on an AAP. Third, marginal structural models control for pre-index and time-varying confounding variables, and the authors endeavored to include controls that are known to be associated with treatment selection and inpatient admissions. However, unmeasured confounders could still exist between treatment cohorts in this study. Finally, this study focused on monotherapy treatment. Future studies should examine the impact of adjunctive therapy on healthcare resource utilization in patients with bipolar disorder.
Conclusions
Adults with bipolar I disorder treated with lurasidone had significantly lower risk of all-cause hospitalization compared to patients treated with olanzapine and quetiapine and lower risk of bipolar I disorder-related hospitalization compared to patients treated with quetiapine and risperidone. Patients treated with lurasidone also reported significantly shorter bipolar I disorder-related hospital LOS compared to patients treated with quetiapine.
Transparency
Declaration of funding
This study was funded by Sunovion Pharmaceuticals Inc.
Declaration of financial/other relationships
X.N., C.D., K.L, G.R.W. and A.L. have disclosed that they are employees of Sunovion. P.V., S.D. and Y.L. have disclosed that they are employees of PRECISIONheor, which received funding from Sunovion to conduct this study.
Author contributions
All authors were directly involved in the design of the study, interpretation of results, drafting of the manuscript and providing final review. S.D. and Y.L. were involved in study conception and design, conducting the analyses, interpretation of study findings, drafting/editing the manuscript and providing final approval. P.V. oversaw the data analysis.
Availability of data and material
This retrospective database study used Medicaid claims data from the IBM MarketScan Research Database (IBM, Somers, NY, USA) spanning 1 January 2014 to 30 June 2019. The claims data that support the findings of this study are from a proprietary administrative claims database and are not publicly available. However, summary data tables are available from the authors upon reasonable request.
Previous presentation
An earlier version of this work was presented as a poster at the Psych Congress; 2020 Sep 10–13; Virtual Conference, USA.
Supplemental Material
Download MS Word (103.8 KB)Acknowledgements
We thank Barbara Blaylock PhD from Blaylock Health Economics LLC for providing medical writing support.
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