Impact of a high intensity, easy access ambulatory program for bipolar disorder

The authors investigated the impact of a high-intensity, easy-access clinic-based program for bipolar disorder on several process and outcome of care variables in a mirror-image design. The Bipolar Disorders Program (BDP) is structured to deliver high levels of medication treatment and standardized psychoeducation according to specific guidelines. Continuity of care and easy accessibility are emphasized by utilizing primary nurse clinicians. We hypothesized that “front-loading” high intensity ambulatory services would improve several process aspects of care and reduce costly emergency and inpatient service utilization and overall mental health expenditures. All bipolars enrolled in or referred to mental health services were enrolled in the BDP, excluding those with moderate to severe dementia. Thus the BDP sample is not highly selected. The 103 patients first completing one year in the BDP were analyzed and compared to pre-BDP baseline. During BDP enrollment, intensity of medication treatment increased without increase in side effects. Patient satisfaction increased significantly as well. Service utilization variables served as the primary measures of outcome. As expected, scheduled ambulatory clinic visits increased. However, emergency room use and psychiatric triage visits decreased significantly. For high utilizers, but not for the entire sample, psychiatric hospital days and total mental health expenditures decreased substantially. Among several patient characteristics, only episode status at BDP entry and history of childhood physical abuse predicted service utilization under the standardized treatment conditions of the BDP. These results indicate that a clinic-based program for bipolar disorder, without extensive community outreach or social rehabilitation components, may improve important process of care variables, and for high utilizers may reduce overall mental health expenditures. Specific pharmacologic and systems mechanisms that may be responsible for the effects are discussed.