Associations between minimally adequate treatment and clinical outcomes among Medicaid-enrolled youth with bipolar disorder

Abstract

Objective

To investigate associations between minimally adequate treatment and clinical outcomes among youth with bipolar disorder.

Methods

This study utilized a retrospective cohort of publicly-insured (Medicaid) youth aged 10–18 years with a new bipolar disorder episode between 2009 and 2013 from 15 geographically diverse states. Four minimally adequate treatment measures were evaluated during a 180-day treatment period: 1) Minimally Adequate Pharmacotherapy: medication (mood stabilizer and/or atypical antipsychotic) possession ratio ≥80%; 2) Minimally Adequate Psychotherapy: ≥8 psychotherapy visits; 3) Minimally Adequate Pharmacotherapy and Psychotherapy, and 4) Recommended Pharmacotherapy with No Antidepressant Monotherapy: no antidepressant prescription without a mood stabilizer and/or atypical antipsychotic. Cox proportional hazards models examined associations between minimally adequate care and time to four clinical outcomes: bipolar disorder-related psychiatric hospitalization or emergency room (ER) visits, deliberate self-harm, and all-cause mortality. We estimated average treatment effects (ATE) using propensity score weighting with stabilized ATE weights to control for confounding.

Results

Hazard of hospitalization was increased among youth receiving minimally adequate psychotherapy (HR = 1.23 [95% CI: 1.04–1.44]) and both minimally adequate pharmacotherapy and psychotherapy (HR = 1.48 [95% CI: 1.12–1.96]) and decreased among youth receiving no antidepressant monotherapy (HR = 0.74 [95% CI: 0.62–0.88]). Hazard of ER visits was increased among youth receiving minimally adequate pharmacotherapy (HR = 1.38 [95% CI: 1.14–1.68]), minimally adequate psychotherapy (HR = 1.35 [95% CI: 1.13–1.61]), and both minimally adequate pharmacotherapy and psychotherapy (HR = 1.66 [95% CI: 1.24–2.24]).

Conclusions

Further research is needed to understand why receipt of minimally adequate care is positively associated with increased mental healthcare utilization among youth with new bipolar disorder episodes.