Inequalities in Swedish care for bipolar disorder

In Sweden, care for bipolar disorder shows inequalities. They are associated both with socioeconomic factors and with gender, according to research from the University of Gothenburg. For instance, lithium — the treatment deemed to have the most stabilizing effect on the disorder — is administered to men more often than to women.

Bipolar disorder involves recurrent depressive and manic episodes, with periods of mood neutrality. The bipolar spectrum affects a few percent of the population. The degree of severity and course of the illness vary greatly among the individuals and subgroups of people concerned.

The aim of treatment is to manage the acute episodes, but also prevent future ones. Since 2000 several new treatments for bipolar disorder, including both new drugs and supplementary psychological methods, have been introduced.

In her thesis at Sahlgrenska Academy, Alina Karanti, a senior consultant psychiatrist at Sahlgrenska University Hospital, studied several factors relating to bipolar disorder. One was how far the Swedish Health and Medical Services Act’s overall objective of equality in care is complied with. This is an aspect of psychiatry that hardly any research has addressed.

“That’s what makes this so interesting. Equality of care hasn’t been studied anywhere near as much in psychiatry as in somatic care, and in bipolar disorder there was virtually nothing,” Karanti says.

Unjustified differences

The results show that women are treated to a greater extent than men with the majority of drugs and psychological methods, while men more often receive lithium, which is the best-documented treatment for stabilizing mood in bipolar disorder.

“We’ve found no medical explanation for women getting different treatment from men. One reason might have been that, for example, men responded better to lithium, but there are no studies supporting this. Rather, a couple of studies suggest that women may respond better to lithium than men do.”

Educational attainment also proved to have a bearing. Patients with no higher education were found to have more often received older types of medication, while patients with higher education had a greater probability of getting psychological treatment.

Participants with higher education also took part more often in psychoeducation, a form of group therapy intended to raise awareness of the disorder and how to identify approaching episodes. This intervention proved to lower the risks of both depressive and manic episodes, and also the need for inpatient care.

Importance of awareness

“One must be aware that there may be rational explanations, even if we don’t succeed in identifying them, for the differences we see. But if people get differing therapies, without medical reasons, depending on their gender or educational attainment, it contravenes the fundamental values of equal treatment and the right to receive the care they need.”

Karanti continues: “This is such a clear finding that clinicians need to be made aware of it. Being mindful is the first step towards change and improvement. Without that awareness, you can’t reflect on what’s being done and not done.”

The clinical data in the thesis were collected from the Swedish National Quality Register for Bipolar Affective Disorder (BipoläR), which includes approximately 60,000 diagnosed patients. The Registrar is Mikael Landén, professor of psychiatry at the University of Gothenburg and supervisor for the thesis.

Title: Bipolar Disorders: Subtypes, treatments, and health inequalities

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