LONG TERM OUTCOMES AND HEALTH INEQUALITIES IN BIPOLAR AFFECTIVE DISORDER WITHIN A UK PRIMARY CARE COHORT (1995-2012)

双相情感障碍（BPAD），或躁狂抑郁症，被认为是全球工作年龄成年人残疾的最常见原因之一。这是一种终身疾病，通常在成年早期开始，并导致患者经历长时间的抑郁或焦虑。目前，这种疾病影响了超过1%的人口，每年花费英国60亿英镑。人们认识到，相对于其他严重精神疾病（SMI），BPAD的研究资金不足。本研究旨在回答两个关于BPAD的问题：1）适当的药物治疗能否改善长期健康结局？2)社会剥夺或您居住的地方是否会导致获得治疗的机会减少和更糟糕的结果？这项研究很重要，因为我们知道BPAD患者经常住院，患有更多的身体和精神疾病，更常见于自杀，并且与其他人群相比更有可能过早死亡。疾病发作可能导致失去工作、人际关系和住房。然而，这些问题的真正程度并没有完全理解，需要澄清。从长远来看，用药物稳定BPAD患者的情绪不仅对他们的生活，而且对他们的家庭，NHS服务的使用和整个社会都有积极的影响。有许多药物被推荐作为长期管理该疾病的适当治疗（包括锂、丙戊酸盐和奥氮平）。支持使用这些药物的证据是基于随机对照试验（RCT），其目的是直接比较药物之间或与安慰剂之间的有效性。然而，这些试验的随访时间通常很短（几个月的时间，而实际上患者服用这些药物多年），涉及的患者数量很少，并且对患者类型非常有选择性（可能不包括“典型”的BPAD患者，他们也有其他健康问题）。因此，目前尚不清楚药物是否真的能减少这些负面结果，也不清楚患者的年龄、性别、种族、社会剥夺、城市化程度和地点是否会影响他们获得治疗和结果。健康治疗中的任何不平等都是不公平的，对社会有害，但它们是可以避免的，识别它们将有助于制定有针对性的干预措施。该项目将使用健康改善网络（THIN）的信息，这是一个全科医生咨询数据库。它包含了超过1000万名患者的诊断和药物处方记录。数据库中有超过20，000名BPAD患者（有史以来最大的BPAD患者组），平均随访时间近8年。当全科医生输入时，数据库会自动匿名更新，因此该项目不需要患者的输入（他们的心理健康可能会因参与此类研究而受到影响）。我将检查患者住院的频率，与紧急精神病团队（危机小组或家庭治疗团队）的联系，有多少自我伤害，自杀死亡和过早死亡。我将看看这些结果是否在特定群体中更常见;通过治疗和社会剥夺。像这样的研究在过去不可能的原因是英国数据库的质量不够高，不包括入学信息。这是第一次将GP和医院数据结合起来检查BPAD。还有人担心，如果不将患者随机分配到治疗组（如RCT），结果会有偏差。在本研究中，将使用多种统计方法来尽量减少可能的偏倚。该项目将全面了解BPAD的影响和结果，并将增加以前从未尝试过的适当治疗方法的证据。

Bipolar affective disorder (BPAD), or manic depression, is recognised as one of the commonest causes of worldwide disability in adults of working age. It is a lifelong illness, which often starts early in adulthood, and causes sufferers to experience prolonged episodes of depression or elation. Currently the illness affects more than 1% of the population and costs the UK £6 billion/year. It is recognised that research into BPAD is underfunded relative to other severe mental illness (SMI). This study aims to answer two questions about BPAD: 1) Can long-term health outcomes be improved by appropriate medication? 2) Does social deprivation or where you live lead to reduced access to treatment and worse outcomes?This study is important because we know that people with BPAD are frequently admitted to hospital, suffer more physical and mental illness, more commonly die by suicide, and are more likely to die early compared to the rest of the population. Episodes of illness can result in loss of jobs, relationships and housing. However the true extent of these problems isn't fully understood and needs to be clarified. Stabilising the mood of people with BPAD with medication should, in the long-term, have a positive impact not only on their lives, but also on their families, use of NHS services, and society as a whole. There are a number of medications recommended as appropriate treatment to manage the condition in the long-term (including lithium, valproate and olanzapine). The evidence supporting the use of these drugs is based on randomised controlled trials (RCTs), which aim to compare directly the effectiveness of drugs with each other, or with a placebo. However, these trials often have short follow-up times (of a matter of months whilst in reality patients take these medications for years), involve small numbers of patients, and are very selective about the types of patients they include (perhaps excluding "typical" people with BPAD, who also have other health problems). So it remains unclear if the medications really do reduce these negative outcomes.It is also not known if a patient's age, sex, ethnicity, social deprivation, urbanicity and location affect their access to treatment and outcomes. Any inequalities in health treatment are unfair and detrimental to society, but they are avoidable and identifying them would allow targeted interventions to be developed.The project will use information from The Health Improvement Network (THIN), a database of General practice (GP) consultations. It contains records of diagnosis and medication prescribed to over 10 million patients. There are over 20,000 patients with BPAD in the database (the largest group of BPAD patients ever examined), with an average follow-up time of almost eight years. The database is updated automatically and anonymously when a GP makes an entry, therefore the project does not require input from patients (whose mental health may be affected by involvement in such a study).I will examine how often patients experience hospitalisation, contact with emergency psychiatric teams (Crisis Teams or Home Treatment teams), how many self harm, die by suicide and die prematurely. I will see if these outcomes are more common in particular groups; by treatment and by social deprivation.The reason studies such as this have not been possible in the past is that UK databases were not of sufficient quality, and did not include information on admissions. This is the first time GP and hospital data will be combined to examine BPAD. Also there was a worry that, by not randomly allocating patients to a treatment (like RCTs), results would be biased. In this study a number of statistical methods will be used to minimise possible bias. The project will give a comprehensive understanding of the effects of, and outcomes in BPAD, and will add to the evidence on appropriate treatment with an approach that has not been attempted before.