Multimorbidity in bipolar disorder and under-treatment of cardiovascular disease: a cross sectional study

Background: Individuals with serious mental disorders experience poor physical health, especially increased rates of cardiometabolic morbidity and premature morbidity. Recent evidence suggests that individuals with schizophrenia have numerous comorbid physical conditions which may be under-recorded and under-treated but to date very few studies have explored this issue for bipolar disorder. Methods:We conducted a cross-sectional analysis of a dataset of 1,751,841 registered patients within 314 primary-care practices in Scotland, U.K. Bipolar disorder was identified using Read Codes recorded within electronic medical records. Data on 32 common chronic physical conditions were also assessed. Potential prescribing inequalities were evaluated by analyzing prescribing data for coronary heart disease (CHD) and hypertension. Results: Compared to controls, individuals with bipolar disorder were significantly less likely to have no recorded physical conditions (OR 0.59, 95% CI 0.54-0.63) and significantly more likely to have one physical condition (OR 1.27, 95% CI 1.16-1.39), two physical conditions (OR 1.45, 95% CI 1.30-1.62) and three or more physical conditions (OR 1.44, 95% CI 1.30-1.64). People with bipolar disorder also had higher rates of thyroid disorders, chronic kidney disease, chronic pain, chronic obstructive airways disease and diabetes but, surprisingly, lower recorded rates of hypertension and atrial fibrillation. People with bipolar disorder and comorbid CHD or hypertension were significantly more likely to be prescribed no antihypertensive or cholesterol-lowering medications compared to controls, and bipolar individuals with CHD or hypertension were significantly less likely to be on 2 or more antihypertensive agents. Conclusions: Individuals with bipolar disorder are similar to individuals with schizophrenia in having a wide range of comorbid and multiple physical health conditions. They are also less likely than controls to have a primary-care record of cardiovascular conditions such as hypertension and atrial fibrillation. Those with a recorded diagnosis of CHD or hypertension were less likely to be treated with cardiovascular medications and were treated less intensively. This study highlights the high physical healthcare needs of people with bipolar disorder, and provides evidence for a systematic under-recognition and under-treatment of cardiovascular disease in this group

The Swedish study on improved contraceptive counselling for immigrant women postpartum

Contraceptive choices postpartum have not previously been studied in Sweden. Being foreign born is a risk factor for induced abortion. Improving postpartum contraceptive counseling could potentially fulfill unmet needs for contraception. This is an organizational case study using a Quality Improvement Collaborative (QIC) within the regular healthcare setting at 3 maternal health clinics in Stockholm. The active phase of the study was Sep2018-Sep2019. Quantitative and qualitative methods were combined. Routine registration of choice of postpartum contraception was introduced at the clinics and analyzed focusing on Swedish born and foreign-born women. Midwives and researchers met continuously, and during the active phase every 2-3 months in learning seminars with around 20 participants. During the learning seminars PDSA-cycles were used and areas of improvements for continuous performance measures were chosen. The midwives decided on and tested multiple evidence-based changes in contraceptive counselling and services during action periods. Goals were set and competency building in areas chosen by the midwifes were held. In addition, both foreign- and Swedish born women gave their input to the improvement areas. Qualitative data was analyzed through content analysis from field notes and verbatim transcripts. Preliminary results show that the proportion of women choosing an effective contraceptive method (SARC or LARC) among immigrant women increased from 40% to 55% when comparing the start and the end of the project. The midwives reported how they had changed their approach when counselling women who were skeptical about contraception and tried to find a new way to meet women's needs. As much as the QIC showed positive results, it was a small-scale study in 3 clinics in one geographical area. A larger study to determine and explain the effectiveness of QIC on the proportion of immigrant women choosing an effective contraceptive method postpartum is planned for 2021-2024