Impact of Bipolar Disorder in Employed Populations

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.

METHODSSystematic 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

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

Functional Impairment

Functional recovery is closely related to the patient&#8217;s ability to work, and this often is delayed or remains incomplete even after BPD symptoms subside.¹⁶ A US study in 2000 reported that more than 60% of patients with BPD remained functionally impaired for at least 2 years after the onset of illness despite resolution of symptoms, which affects interpersonal relationships and the ability to work productively.¹⁷

A US longitudinal analysis in 2005 reported that at 2 years, 4.5 years, and 7-8 years of follow-up, objective work-functioning scores of BPD subjects were significantly lower than those with unipolar depression (psychotic and nonpsychotic).¹⁸

Stigma in the Workplace

The negative impact of BPD also may extend to family members and caregivers. A multivariate analysis in 1999 reported that more than 90% of US caregivers for people with BPD experienced moderate distress in at least 1 of the following burden domains: the patient&#8217;s problematic behavior (eg, violence, unpredictability); the patient&#8217;s role dysfunction at work or home; and adverse effect on others (eg, impact on caregiver&#8217;s work or social time).²⁰ More than 50% experienced severe levels of burden, and there was an association between higher stress levels and depressive episodes.²⁰

In 1991, the National Institute of Mental Health estimated that work absences resulting from caregivers being required to care for family members with BPD cost the United States approximately $6 billion per year, or 13% of the total cost of BPD to the United States ($45 billion).¹³

Importance of Awareness, Recognition, and Diagnosis

A North American qualitative analysis highlighted some of the management strategies used by employees with BPD in the workplace, including removing themselves from their work setting when a depressive episode occurs, changing the nature and length of their workload when symptoms arise, seeking emotional or practical support of coworkers, and seeking assistance from their healthcare team.¹⁹ The study concluded that people with BPD can be very valuable and productive employees, bringing creativity, energy, and passion to the workplace, and it is important to identify means to help these employees find appropriate and fulfilling work.¹⁹

With the growing list of therapeutic options, it is important for clinicians to continually refine treatment strategies and develop an approach that is specifically designed to meet the needs of each patient. A risk stratification quintile analysis of a large cohort of US employees reported that although people with the &#8220;highest severity&#8221; of BPD made up only a small proportion of the total employees with BPD (2.4%), these individuals incurred a high proportion of healthcare costs (20%).^4,14 This analysis demonstrated that not all employees exhibit the same cost patterns and highlighted the importance of differentiating low- and high-risk BPD patients in order to design appropriate interventions based on risk levels.^4,14

It has been suggested that employers and insurers need to implement programs to encourage timely diagnosis and identification of employees with BPD.⁵ However, the literature search did not identify any specific examples of employer-initiated programs aimed at improving the workplace productivity of employees with BPD.

DISCUSSION

&#8226; Low rates of help-seeking by the individual. Employees with BPD often fear stigma and discrimination in the workplace, which discourages them from seeking help.1,19

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 BPD in an employed population.

Author Affiliations: From Medaxial Limited (KEL, KSL), London, England; and AstraZeneca Pharmaceuticals LP (MKH), Wilmington, DE.

Funding Source: This study was supported by a research grant from AstraZeneca Pharmaceuticals LP.

Author Disclosure: Ms Laxman and Ms Lovibond report receiving payment from AstraZeneca for their involvement in undertaking this research and preparing this manuscript. Dr Hassan is an employee of AstraZeneca, the funder of the study and a manufacturer of a drug indicated for bipolar disorder.

Authorship Information: Concept and design (KEL, KSL, MKH); acquisition of data (KEL); analysis and interpretation of data (KEL, MKH); drafting of the manuscript (KEL, MKH); critical revision of the manuscript for important intellectual content (KEL, KSL, MKH); obtaining funding (MKH); and supervision (KSL, MKH).

Address correspondence to: Mariam K. Hassan, BPharm, PhD, AstraZeneca Pharmaceuticals LP, PO Box 15437, 1800 Concord Pike, Wilmington, DE 19850. E-mail: mariam.hassan@astrazeneca.com.

2. Matza L, De-Lissovoy G, Sasane R, Pesa J, Mauskopf J. The impact of bipolar disorder on work loss. Drug Benefit Trends. 2004;16(9):479-481.

4. Brook RA, Rajagopalan K, Kleinman NL, Smeeding JE, Brizee TJ, Gardner HH. Incurring greater health care costs: risk stratification of employees with bipolar disorder. Prim Care Companion J Clin Psychiatry. 2006;8(1):17-24.

6. Rajagopalan K, Kleinman NL, Brook RA, Gardner HH, Brizee TJ, Smeeding JE. Costs of physical and mental comorbidities among employees: a comparison of those with and without bipolar disorder. Curr Med Res Opin. 2006;22(3):443-452.

8. Hirschfeld RM, Calabrese JR, Weissman MM, et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64(1):53-59.

10. Reville R, Bhattacharya J, Sager Weinstein L. New methods and data sources for measuring economic consequences of workplace injuries. Am J Ind Med. 2001;40(4):452-463.

12. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5-14.

14. Gardner HH, Kleinman NL, Brook RA, Rajagopalan K, Brizee TJ, Smeeding JE. The economic impact of bipolar disorder in an employed population from an employer perspective. J Clin Psychiatry. 2006;67(8):1209-1218.

16. Coryell W, Scheftner W, Keller M, Endicott J, Maser J, Klerman G. The enduring psychosocial consequences of mania and depression. Am J Psychiatry. 1993;150(5):720-727.

18. Goldberg JF, Harrow M. Subjective life satisfaction and objective functional outcome in bipolar and unipolar mood disorders: a longitudinal analysis. J Affect Disord. 2005;89(1-3):79-89.

20. Perlick D, Clarkin J, Sirey J, et al. Burden experienced by caregivers of persons with bipolar affective disorder. Br J Psychiatry. 1999;175:56-62.

22. Birnbaum HG, Shi L, Dial E, Oster EF, Greenberg PE, Mallett DA. Economic consequences of not recognizing bipolar disorder patients: a cross-sectional descriptive analysis. J Clin Psychiatry. 2003;64(10):1201-1209.

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