System interventions incorporate multiple elements, and inevitably overlap with the domains of patient and provider maneuvers. Furthermore, studies of system reorganization strategies do not easily allow "unbundling" of the different components to identify the most potent elements. Nonetheless, such system interventions are clear to specify and clear to study. Historically, the establishment of "lithium" clinics for bipolar disorder was an early example of a relatively pure system intervention, as reviewed by Gitlin and Jamison (1984). The staff of these clinics fostered a clear understanding of the medical model for bipolar disorder, built care along multidisciplinary lines, and established routines for the evaluation and monitoring of patients, as well as the provision of basic psychoeducation. Virtually no advances in systems interventions in bipolar disorder had been reported until the launching of two randomized, controlled studies (comparison condition is treatment-as-usual), both of which are still ongoing. In the first program, Bauer (2001) is comparing a "comprehensive patient education package", with specific treatment guidelines for providers, and a special nurse provider care facilitation/treatment with "usual care".
In the second similar study, Simon et al. (2002) are using a collaborative treatment model involving the same structured psychoeducation for patients, feedback of "automatic" monitoring results and algorithm-based medication recommendations to providers, and a nurse care manager to provide monthly telephone monitoring, outreach, psychoeducation, and care coordination. While results for bipolar disorder are not yet available, the findings from the depression literature are very clear: nine randomized, controlled treatment trials involving depressed patients in primary care show strong positive results from the adoption of a model where therapeutic maneuvers include some degree of care management, reorganization of typical care pathways, and incorporation of patient and provider education and support (Von Korff & Goldberg, 2001). Similarly, in a US multicenter clinical trial involving practice nurses in care management over 24 months, remission rates improved by 33 percentage points compared to the "treatment-as-usual group" (a remarkable 74% remission rate versus 41% at 24 months; Rostetal., 2002). Such results, paralleling the success in employing chronic disease-management strategies for diabetes (Renders et al., 2001), suggest that bipolar disorder will be best served by a chronic disease model involving an emphasis on system reorganization to include nurse care facilitation, telephone interventions, and full use of a multidisciplinary "patient care team" (Wagner, 2000)—but in conjunction with the patient and provider programs described earlier.
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