The quality of mental health care for people with bipolar disorders in the Italian mental health system: the QUADIM project

Abstract

Background The assessment of the quality of care pathways delivered to people with severe mental disorders in a community-based system remains uncommon, especially using healthcare utilization databases. The aim of the study was to evaluate the quality of care provided to people with bipolar disorders taken-in-care by mental health services of four Italian areas (Lombardy, Emilia-Romagna, Lazio, province of Palermo). Methods Thirty-six quality indicators were implemented to assess quality of mental health care for patients with bipolar disorders, according to three dimensions (accessibility and appropriateness, continuity, and safety). Data were retrieved from healthcare utilization (HCU) databases, which contain data on mental health treatments, hospital admissions, outpatient interventions, laboratory tests and drug prescriptions. Results 29,242 prevalent and 752 incident cases taken-in-care by regional mental health services with a diagnosis of bipolar disorder in 2015 were identified. Age-standardized treated prevalence rate was 16.2 (per 10,000 adult residents) and treated incidence rate 1.3. In the year of evaluation, 97% of prevalent cases had ≥ 1 outpatient/day-care contacts and 88% had ≥ 1 psychiatric visits. The median of outpatient/day-care contacts was 9.3 interventions per-year. Psychoeducation was provided to 3.5% of patients and psychotherapy to 11.5%, with low intensity. 63% prevalent cases were treated with antipsychotics, 71.5% with mood stabilizers, 46.6% with antidepressants. Appropriate laboratory tests were conducted in less than one-third of prevalent patients with a prescription of antipsychotics; three quarters of those with a prescription of lithium. Lower proportions were observed for incident patients. In prevalent patients, the Standardized Mortality Ratio was 1.35 (95% CI: 1.26–1.44): 1.18 (1.07–1.29) in females, 1.60 (1.45–1.77) in males. Heterogeneity across areas was considerable in both cohorts. Conclusions We found a meaningful treatment gap in bipolar disorders in Italian mental health services, suggesting that the fact they are entirely community-based does not assure sufficient coverage by itself. Continuity of contacts was sufficient, but intensity of care was low, suggesting the risk of suboptimal treatment and low effectiveness. Care pathways were monitored and evaluated using administrative healthcare databases, adding evidence that such data may contribute to assess the quality of clinical pathways in mental health.

Just Not Enough: Utilization of Outpatient Psychotherapy Provided by Clinical Psychologists for Patients With Psychosis and Bipolar Disorder in Switzerland

“…These preliminary findings are in line with prior studies indicating underutilization of psychotherapy—especially for people diagnosed with psychosis and bipolar disorder—in the USA, UK, Australia, Germany, and Italy, 6 - 8 , 10 - 12 , 14 , 18 see also Burgess-Barr et al 38 for an international overview. Low utilization rates were replicated in the present sample, even though Switzerland and in particular the catchment area described in this manuscript is known for a comprehensive health care system associated with a high density of inpatient and outpatient health care providers.…”

“…Research, however, indicates a substantial undersupply of psychotherapy for people with psychosis 6 - 9 and bipolar disorder 10 , 11 and a gap between guideline recommendations and utilization.…”

“…Barbato et al 10 showed that the rate of patients with bipolar disorder who utilized individual psychotherapy was estimated at 6.1%. Later research 11 estimated the use of psychotherapy at 11.5% for people with bipolar disorders, but the authors also highlight that treatment was characterized by low intensity.…”

Association of Antipsychotic Polypharmacy and Two-Year All-Cause Mortality: A Population-Based Cohort Study of 33,221 Italian Continuous Users

“…This finding is consistent with broader evidence indicating excess mortality among psychotic patients, as further evidenced by a recent meta-analysis that reported a gender-pooled standardized mortality ratio (SMR) of 3.08 (95% CI: 2.88-3.31), showing a persistently high risk over the years [31]. Moreover, schizophrenia's serious impact on life expectancy was underscored by another meta-analysis that associated the presence of this disorder with an average loss of 14.5 years of life expectancy (95% CI: 11.2-17.8), reinforcing the urgent need for targeted interventions [32]. The number of years of life lost, the higher mortality rate, and the lack of improvement over time call for the urgent need of interventions and initiatives to reduce this gap.…”

Editorial: Case reports in personality disorders

“…So far, there is no evidence about the effectiveness of pharmacological treatment (which has only shown mild efficacy on impulse control and emotional regulation) ( 5 ), while it seems that psychological treatment is more efficacious, although there is no agreement in the literature on which treatment should be the first-line choice ( 6 , 7 ). However, despite the acquisitions of recent decades that attest that personality disorders should be treated with psychotherapeutic interventions, the offering of treatment provided is predominantly anchored to pharmacotherapy alone ( 8 ).…”