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，被认为是全球工作年龄成年人残疾的最常见原因之一。这是一种终生疾病，通常在成年早期开始，并导致患者经历长期的抑郁或兴奋。目前，这种疾病影响了超过1%的人口，每年造成英国60亿英镑的损失。人们认识到，与其他严重的精神疾病(SMI)相比，对BPAD的研究资金不足。这项研究旨在回答关于BPAD的两个问题：1)适当的药物能否改善长期健康结果？2)社会剥夺或你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，与其他人相比，BPAD患者经常住院，遭受更多的身体和精神疾病，更常死于自杀，更有可能过早死亡。疾病发作可能会导致失去工作、人际关系和住房。然而，这些问题的真正程度还没有完全理解，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有积极的影响，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。有一些药物建议作为适当的治疗方法来长期控制这种情况(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)，该试验旨在直接比较药物之间或与安慰剂的有效性。然而，这些试验的随访时间通常很短(只有几个月，而实际上患者要服用这些药物数年)，涉及的患者数量很少，而且对纳入的患者类型非常挑剔(可能不包括患有BPAD的“典型”患者，他们也有其他健康问题)。因此，目前尚不清楚这些药物是否真的减少了这些负面结果。也不知道患者的年龄、性别、种族、社会贫困、城市化和地理位置是否会影响他们获得治疗的机会和结果。医疗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，识别它们将允许制定有针对性的干预措施。该项目将使用来自全科医学(GP)咨询数据库健康改善网络(Thin)的信息。它包含向1000多万名患者开出的诊断和用药记录。该数据库中有20,000多名BPAD患者(这是有史以来检查过的最大的BPAD患者群体)，平均随访时间近8年。当全科医生输入条目时，数据库会自动匿名更新，因此该项目不需要患者提供信息(他们的精神健康可能会因参与此类研究而受到影响)。我将检查患者入院的频率、与紧急精神科小组(危机小组或家庭治疗小组)的联系、有多少人自我伤害、自杀死亡和过早死亡。我会看看这些结果在特定群体中是否更常见：通过治疗和社会剥夺。过去不可能进行这样的研究是因为英国的数据库质量不够高，也没有包括招生信息。这是首次将全科医生和医院数据结合起来检查BPAD。还有一种担心是，不随机分配患者接受治疗(如随机对照试验)，结果会有偏差。在这项研究中，将使用一些统计方法来最大限度地减少可能的偏差。该项目将全面了解BPAD的效果和结果，并将增加关于采用以前从未尝试过的方法进行适当治疗的证据。

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.