title: Delays before Diagnosis and Initiation of Treatment in Patients Presenting to Mental Health Services with Bipolar Disorder.
abstract: BACKGROUND
  Bipolar disorder is a significant cause of morbidity and mortality. Although existing treatments are effective, there is often a substantial delay before diagnosis and treatment initiation. We sought to investigate factors associated with the delay before diagnosis of bipolar disorder and the onset of treatment in secondary mental healthcare.
  
  
  METHODS
  Retrospective cohort study using anonymised electronic mental health record data from the South London and Maudsley NHS Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register on 1364 adults diagnosed with bipolar disorder between 2007 and 2012. The following predictor variables were analysed in a multivariable Cox regression analysis: age, gender, ethnicity, compulsory admission to hospital under the UK Mental Health Act, marital status and other diagnoses prior to bipolar disorder. The outcomes were time to recorded diagnosis from first presentation to specialist mental health services (the diagnostic delay), and time to the start of appropriate therapy (treatment delay).
  
  
  RESULTS
  The median diagnostic delay was 62 days (interquartile range: 17-243) and median treatment delay was 31 days (4-122). Compulsory hospital admission was associated with a significant reduction in both diagnostic delay (hazard ratio 2.58, 95% CI 2.18-3.06) and treatment delay (4.40, 3.63-5.62). Prior diagnoses of other psychiatric disorders were associated with increased diagnostic delay, particularly alcohol (0.48, 0.33-0.41) and substance misuse disorders (0.44, 0.31-0.61). Prior diagnosis of schizophrenia and psychotic depression were associated with reduced treatment delay.
  
  
  CONCLUSIONS
  Some individuals experience a significant delay in diagnosis and treatment of bipolar disorder after initiation of specialist mental healthcare, particularly those who have prior diagnoses of alcohol and substance misuse disorders. These findings highlight a need for further study on strategies to better identify underlying symptoms and offer appropriate treatment sooner in order to facilitate improved clinical outcomes, such as developing specialist early intervention services to identify and treat people with bipolar disorder.
authors.affiliation: King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Rashmi
authors.initials: R
authors.lastname: Patel
authors.affiliation: South London and Maudsley NHS Foundation Trust, Biomedical Research Centre Nucleus, London, United Kingdom.
authors.forename: Hitesh
authors.initials: H
authors.lastname: Shetty
authors.affiliation: King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Jackson
authors.affiliation: South London and Maudsley NHS Foundation Trust, Biomedical Research Centre Nucleus, London, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Broadbent
authors.affiliation: King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Robert
authors.initials: R
authors.lastname: Stewart
authors.affiliation: King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Jane
authors.initials: J
authors.lastname: Boydell
authors.affiliation: King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Philip
authors.initials: P
authors.lastname: McGuire
authors.affiliation: King's College London, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Taylor
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D001714:Bipolar Disorder / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*; D057210:Delayed Diagnosis; D003863:Depression / Q000150:complications / Q000175:diagnosis; D005260:Female; D006760:Hospitalization / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D006801:Humans; D008131:London; D008297:Male; D017533:Marital Status; D008605:Mental Health Services / Q000941:ethics / Q000706:statistics & numerical data*; D008875:Middle Aged; D012044:Regression Analysis; D012189:Retrospective Studies; D012559:Schizophrenia / Q000150:complications / Q000175:diagnosis; D012737:Sex Factors; D019966:Substance-Related Disorders / Q000150:complications / Q000175:diagnosis
chemical_list: D014150:Antipsychotic Agents