AJMC

Impact of Bipolar Disorder in Employed Populations

Published Online: November 15, 2008
Kiran E. Laxman, BSc; Kate S. Lovibond, BSc, MSc; and Miriam K. Hassan, BPharm, PhD

Objective: To review literature on the impact of bipolar disorder on the workplace, with respect to costs to employers, workplace productivity and functioning, and any employer-initiated programs implemented with the aim of improving work attendance and performance.

Study Design: Systematic literature review.

Methods: Original studies relating to bipolar disorder in the workplace were identified from PubMed and EMBASE using a reproducible, systematic search strategy in July 2007. There were no constraints on publication dates. Results were first evaluated by title and/or abstract. Full manuscripts of potentially relevant papers then were obtained and assessed for inclusion. Productivity data were extracted in terms of absenteeism, short-term disability, presenteeism, and any associated cost burden to US employers.

Results: Seventeen studies met search criteria and were included in this review. The data indicate that bipolar disorder imposes a significant financial burden on employers, costing more than twice as much as depression per affected employee. A large proportion of the total cost of bipolar disorder is attributable to indirect costs from lost productivity, arising from absenteeism and presenteeism. The presence of comorbid conditions and stigma in the workplace may lead to delays in accurate diagnosis and effective management of bipolar disorder.

Conclusion: Bipolar disorder among the working population can have a significant, negative effect on work relationships, attendance, and functioning, which can lead to substantial costs to US employers arising from lost productivity. There is a need for workplace initiatives to address the health and cost consequences of bipolar disorder within an employed population.

(Am J Manag Care. 2008;14(11):757-764)

Bipolar disorder (BPD; also known as manic-depressive disorder) is a chronic mental illness characterized by recurrent, dramatic mood changes.1-6 Individuals with BPD cycle between a range of emotions that disrupt phases of near-normal behavior, often alternating between intense feelings of exhilaration (manic episodes) and sadness (depressive episodes).1-6

Manic episodes are characterized by a euphoric state of mind and are associated with feelings of elation, grandiosity, impulsiveness, hyperactivity, distractibility, irritability, and excessive libido.1,3 Conversely, depressive episodes are associated with feelings of despair, hopelessness, lethargy, guilt, anxiety, violence, and suicidal ideation and activity.1,3 Some people with BPD experience mixed episodes, with both manic and depressive features.1,3,5

Bipolar disorder, especially the depressive phase, is associated with high levels of morbidity, disability, and premature mortality.6 In 2000, the World Health Organization estimated that BPD was the fifth leading cause of disability worldwide among young adults (ie, 15-44 years of age).7 In the United States, the lifetime prevalence of BPD is estimated at 3.7%.8

Bipolar disorder has a substantial effect on many aspects of a patient’s life and is a source of significant economic burden.5 The achievement of academic and occupational ambitions is impeded from an early age because the onset of BPD generally occurs during adolescence or early adulthood and the illness continues for the remainder of a patient’s working life.1 Impaired functioning may remain for many patients even after BPD symptoms subside during a remission.3,6,9

The objective of this review was to identify the impact of BPD on the workplace, with respect to costs to employers, workplace productivity and functioning, and any employer-initiated programs or management strategies implemented to improve work attendance and performance.

METHODS
Systematic searches of PubMed and EMBASE were performed to identify studies addressing the impact of BPD in an employed population. This search was conducted as part of a wider review into the impact of mental illness in an employed population. Publications were retrieved in July 2007 using a reproducible search strategy, which included search terms such as absenteeism, bipolar disorder, disability, employee, employer-initiated programs, household earnings, presenteeism, and productivity. There were no constraints on publication dates.

References were imported into a database (EndNote, version X1, Thomson ResearchSoft, Carlsbad, CA), and duplicates were deleted. The results were then evaluated by title and/or abstract with the aim of rejecting any not written in English and selecting those specific to working adults and relevant to workplace productivity. Full manuscripts of potentially relevant papers were obtained and assessed for inclusion. Articles were included if they quantifiably measured productivity outcomes or provided examples of  employer-initiated programs to improve workplace performance. US papers were extracted and included in this publication.

RESULTS
After the removal of duplicates and the addition of papers found ad hoc or already known to the reviewers, the PubMed and EMBASE searches produced 16 original papers and 1 poster presentation (Table). These studies fell into 3 categories: 8 retrospective studies of administrative claims data, 5 studies of cross-sectional survey data, and 4 prospective, naturalistic studies using patient interview data. Retrospective analysis of administrative claims databases can provide useful information on healthcare resource use and lost productivity in terms of sick leave and disability compensations.10,11 These studies are inexpensive and less time consuming, but may lack information on productivity outcomes measures that do not result in claims.10,11 Cross-sectional surveys can collect information on presenteeism and work performance that are not available from administrative claims data.10,11 However, survey data may lack medical information and are susceptible to nonresponse and recall bias.10,11 Prospective, naturalistic studies may offer an opportunity to collect follow-up data on the impact of illness on functional and occupational outcomes, but may be sensitive to sample size and generalizability issues.10,11 Despite their limitations, the use of different data sources and study methods can provide a more complete picture of the impact of illness in employed populations. Productivity data were extracted in terms of absenteeism, short-term disability, and presenteeism, along with any associated cost burden to US employers.

Impact on Employed Populations
Direct and Indirect Costs to Employers. Lost productivity due to BPD imposes a significant economic burden on employers. A study analyzing data from 6 large US corporations found BPD to be the most expensive mental health condition in terms of medical care and lost productivity.12 The study utilized the MEDSTAT MarketScan Health and Productivity Management Database containing person-level information on nearly 375,000 individuals employed by the corporations between 1997 and 1999 and found that the cost of chronic maintenance of BPD (US $64.10 per eligible employee) was 2.5-fold greater than the cost of the next most expensive mental health condition, depression ($24.02).12 Indirect costs due to work absences and short-term disability losses accounted for 51% and 50%, respectively, of each of these costs.12 Treatment of severe depressive and manic episodes of BPD also ranked third ($22.70) and eighth ($2.71), respectively, in the top-10 list; 58% and 50% of each cost was attributed to work absences and short-term disability losses, respectively.12

In 1991, the National Institute of Mental Health estimated the annual cost of BPD to the United States as $45 billion, of which only $7 billion was estimated to be direct treatment costs.13 The remaining $38 billion of indirect costs included lost productivity of wage earners ($18 billion), homemakers ($3 billion), institutionalized patients ($3 billion), individuals who committed suicide ($8 billion), and caregivers of BPD family members ($6 billion).13

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Issue: November 2008
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