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The American Journal of Managed Care November 2008
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Impact of Bipolar Disorder in Employed Populations
Kiran E. Laxman, BSc; Kate S. Lovibond, BSc, MSc; and Miriam K. Hassan, BPharm, PhD

Impact of Bipolar Disorder in Employed Populations

Kiran E. Laxman, BSc; Kate S. Lovibond, BSc, MSc; and Miriam K. Hassan, BPharm, PhD
This systematic review examines the impact of bipolar disorder on employee attendance and functioning at work, along with the associated economic burden to US employers.

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 has a considerable impact on the workplace and imposes a substantial financial burden on employers.
  • Indirect costs from lost productivity are a significant driver of the costs associated with bipolar disorder because of the increased rates of absenteeism and reduced productivity among employees with the condition.
  • Misdiagnosis and delays in seeking professional help are common and contribute to this burden.
  • There is a need for employer-initiated programs that may reduce indirect costs by ensuring early, accurate diagnosis and effective management, reducing stigma in the workplace, and encouraging better occupational relationships.
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.

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.

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

Individuals with BPD also incur a substantial burden of general medical comorbidity. A retrospective analysis of data extracted from the Human Capital Management Services Research Reference Database between 2001 and 2002 revealed that BPD is associated with multiple, costly, comorbid conditions, both mental (eg, affective disorders, schizophrenia, dissociative/ personality disorders) and physical (eg, endocrine, metabolic, immunity, and circulatory disorders).6 Bipolar disorder also was associated with significantly greater costs in the poisoning/medical/drugs category, which the study accounted for by the fact that the depressive phase of BPD often is linked with suicidal ideation, with 25%-50% of BPD patients attempting suicide at least once.6

A related study reported that US employees with BPD had about 2 to 3 times higher costs than employees without BPD in several physical health condition categories, including headaches and migraines, intervertebral disc disorders, hyperlipidemia, and other nontraumatic joint disorders.14

Work Time Lost and Associated Costs. A diagnosis of BPD is associated with an increased likelihood of missing work because of illness.5,14 A retrospective analysis of data from the Human Capital Management Services Research Reference Database relating to health benefit costs and healthrelated absences during 2001-2002 reported that employees with BPD had significantly more health-related absences from work than employees without the disorder.5,14 Individuals with BPD missed an average of 18.9 workdays each year, significantly more (P ≤.05) than employees without BPD, who missed an average of 7.4 workdays annually.5,14 The majority of this lost time (58%) occurred under the short-term disability benefit.5,14

Total costs associated with this absenteeism were approximately 2.5-fold higher for employees with BPD than for those without BPD ($1995 vs $777; P ≤.05).4,5 A breakdown revealed that employees with BPD were consistently more costly than employees without BPD across all types of absences, including sick leave ($489 vs $353; P ≤.05), shortterm disability ($975 vs $255; P ≤.05), long-term disability ($118 vs $6; P ≤.05), and workers’ compensation ($413 vs $163; P ≤. 05).4,5

The same study reported that when present at work, the average hourly productivity of employees with BPD was similar to that of employees without BPD.5 However, because of their high rates of absenteeism, on an annual basis, the overall productivity loss was significantly different, with an annual output 20% lower than that of employees without BPD (P 5

In terms of total healthcare benefit costs, employees with BPD were $6836 more expensive per year than employees without the disorder ($9983 vs $3147; P <.05).4,14 Total costs also were 59% greater than those for employees with other mental disorders ($9983 vs $6268; P <.05).4,14

A retrospective analysis of the MEDSTAT MarketScan Health and Productivity Management Database of 320,000 employees from 6 large US employers in 2000 concluded that BPD has a substantial impact on work time lost.2 Employees with BPD were absent significantly more hours per year (55 h vs 21 h; P = .009) than employees without BPD, while short-term disability payments were significantly larger for employees with BPD than for both employees without BPD ($1231 vs $131; P <.001) and employees with depression ($1231 vs $741; P = .004).2

A regression analysis of BPD and major depressive disorder indicated that productivity loss due to BPD was twice that associated with depression.15 Using data from 3378 workers who responded to the National Comorbidity Survey Replication conducted in 2001-2003, it was estimated that employees with BPD had 65.5 lost workdays per year due to absenteeism and presenteeism, significantly more than those with major depressive disorder, who missed 27.2 workdays per year (P = .05).15 The study attributed the higher rate of work loss associated with BPD to the more severe and persistent depressive episodes experienced; these lasted 134-164 days, whereas those for major depression lasted, on average, 98 days (P = .01).15

Annual costs were significantly greater for employees with BPD than for those with major depressive disorder in terms of both absenteeism ($4067 vs $1420; P = .05) and presenteeism ($5184 vs $2961; P = .05).15 When projections were scaled up to the total US workforce, the same study estimated that BPD costs employers $14.1 billion per year due to absenteeism and presenteeism.15 This was almost half the estimated cost for major depressive disorder ($36.6 billion), even though BPD is 6 times less prevalent.15

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