Does the systematic use of stimulus reduction shorten hospitalization in acute mania? A pilot study

Abstract

Objective: Bipolar disorder (BD) is a serious mental disorder causing not only suffering and disability, but also substantial economic burden. Costs of hospitalization represent the largest share of direct illness cost. Several clinical guidelines recommend stimulus reduction (SR) during the treatment of patients hospitalized for mania. To date, however, no clinical trials have investigated the efficacy of SR in mania. In this pilot study, we examined the effect of training inpatient staff to use systematic SR on length of stay (LOS) of our patients. Method: This was a controlled intervention study of adult patients hospitalized due to an acute manic episode (ICD-10 criteria). Treatment as usual (TAU) (N=37) was compared with treatment after systematic training of staff in SR (N=34). LOS was the primary outcome. Young Mania Rating Scale (YMRS), Montgomery-Åsberg Depression Rating Scale (MADRS) and Clinical Global Impression (CGI) at admission and discharge were also measured. Results: During hospitalization the YMRS, MADRS and CGI improved significantly in both groups, indicating symptom remission during treatment. The LOS in the TAU was 26.9 days (SD 12.2) and in the SR 28.4 days (SD 11.7). No significant differences emerged in LOS or in clinical outcome measures between the groups. Conclusions: To our knowledge, this is the first study evaluating the use of SR during hospitalization for acute manic episode. Systematic training of staff in SR did not shorten LOS. Effectiveness of SR during hospitalization remains unclear, and further studies are needed to clarify the role of SR in treatment guidelines. Bipolar disorder (BD) is a serious and long-lasting mood disorder causing considerable suffering and disability (1). Hospital admission is generally required in both acute manic episode and severe depressive episode with suicidal ideation or plans (2). Although BD patients spend a longer time in depression than in mania during the course of their illness (3,4), from an economic standpoint mania appears to be the primary cost driver in BD hospitalizations (2). Therefore, any intervention in manic patients that could reduce the need for hospitalization, or shorten the length of stay (LOS) during inpatient treatment, would have a major effect on diminishing the suffering of patients and costs of hospitalization (5). When treating mania or hypomania, several treatment guidelines recommend a calm environment and stimulus reduction (SR) (6,7,8). SR includes, for instance, increasing the amount of sleep and limiting activity. To date, however, no studies have investigated the effectiveness of SR in patients hospitalized due to acute manic episode. The aim of our pilot study was to perform a controlled intervention trial to investigate the effect of training staff in the use of systematic SR (SSR group) in treating hospitalized patients with an acute manic episode, and to compare this with treatment as usual (TAU group) during acute manic episode. We hypothesized that the use of SR in treatment would shorten LOS in the inpatient ward.