Specialised mood disorder clinic v. standard care for out-patients with bipolar disorder

The recent paper by Kessing et al ¹ was an interesting read. However, the likelihood of the findings being useful in a setting outside Denmark could reduce the paper's relevance to the international audience. First, the vast difference between the type of treatment received by patients in the mood disorder clinic and standard out-patient care makes it almost impossible to identify the features of the clinic that make it successful, such that they may be replicated to improve service elsewhere. Although the authors go into significant detail with regard to the type of treatment and support received by the patients in the clinic, there is very little information on the patients who went through standard care. If standard care is an appointment with a general practitioner or a private psychiatrist without any support from community mental health teams, then generalising the results to the UK might be problematic as these patients would normally be with community mental health teams with some or other type of enhanced care programme approach. Second, when refusal rates are as high as the authors mentioned in this article – out of 474 eligible patients only 158 participated in the trial – a judgement must be made as to how far the volunteers that remain can be considered representative of the target population. They might, for example, in this study be younger on average than the refusers. Is this important in relation to the study question? Third, the authors refer to psychopharmacological treatments in standard care being ‘more likely to be based on the preferences of the individual physician than on national and international guidelines’; however, they make no effort to control or correct for these factors in the analysis of results, although it has been recognised that patients from the mood disorder clinic are more likely to use mood stabilisers. Finally, the cost difference between standard care and the mood disorder clinic is mainly due to the in-patient costs for patients on standard care. This again highlights the need for adjusting the effect of medications and this would have at the least given us some better understanding about the pharmacological treatment being offered with standard care.