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BACKGROUND: The economic burden of depression in the United States-including major depressive disorder (MDD), bipolar disorder, and dysthymia-was estimated at $83.1 billion in 2000. We update these findings using recent data, focusing on MDD alone and accounting for comorbid physical and psychiatric disorders. METHOD: Using national survey (DSM-IV criteria) and administrative claims data (ICD-9 codes), we estimate the incremental economic burden of individuals with MDD as well as the share of these costs attributable to MDD, with attention to any changes that occurred between 2005 and 2010. RESULTS: The incremental economic burden of individuals with MDD increased by 21.5% (from $173.2 billion to $210.5 billion, inflation-adjusted dollars). The composition of these costs remained stable, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs. Only 38% of the total costs were due to MDD itself as opposed to comorbid conditions. CONCLUSIONS: Comorbid conditions account for the largest portion of the growing economic burden of MDD. Future research should analyze further these comorbidities as well as the relative importance of factors contributing to that growing burden. These include population growth, increase in MDD prevalence, increase in treatment cost per individual with MDD, changes in employment and treatment rates, as well as changes in the composition and quality of MDD treatment services. Language: en

Objective: Nonadherence is a major challenge in schizophrenia treatment. While long-acting (depot) antipsychotic medications are often recommended to address adherence problems, evidence on the comparative effectiveness of depot versus oral antipsychotics is inconsistent. We hypothesize that this inconsistency could be due to systematic differences in study design. This review evaluates the effect of study design on the comparative effectiveness of antipsychotic formulations. The optimal use of different antipsychotic formulations in a general clinical setting depends on better understanding of the underlying reasons for differences in effectiveness across research designs. Data Sources: A PubMed literature review targeted English-language studies (2000–2011) with information on relapse, hospitalization, or allcause discontinuation for depot and oral antipsychotic treatment arms in schizophrenia. The time frame was chosen to reflect research focused on the newer generation of antipsychotic agents. The search required at least 1 term from each of the following categories: (1) schizophrenia; (2) inject, injection, injectable, injectables, injected, depot, long-acting; and (3) iloperidone, fluphenazine, haloperidol, paliperidone, risperidone, olanzapine, asenapine, flupentixol, flupenthixol, lurasidone, clopenthixol, fluspirilene, zuclopentixol, zuclopenthixol. Study Selection: Thirteen relevant studies were identified by 2 independent reviewers; these studies included information on 19 depot-oral comparisons. Data Extraction: Age- and gender-adjusted risk ratios (RRs) (depot/ oral) were calculated for the identified endpoints and pooled by study design (randomized controlled trial [RCT], prospective observational, and retrospective observational). Meta-analysis with random effects was used to estimate the pooled RRs, by study design. Average conversion factors between study designs were calculated as the ratios of pooled RRs. Results: Meta-analysis of adjusted endpoints showed no apparent benefit of depot over oral formulations in RCTs, with an RR of 0.89 (P = .416). In contrast, there was a significant advantage for depot formulations in other study designs (prospective RR = 0.62 [P < .001]; retrospective RR = 0.56 [P < .001]). These imply conversion factors of 1.43 and 1.59 between RCTs and prospective and retrospective designs, respectively. Conclusions: The comparative effectiveness of antipsychotic formulations is sensitive to research design. Depot formulations displayed significant advantages in nonrandomized observational studies, whereas in RCTs no difference was observed. The estimated conversion factors may facilitate comparison across studies.

Background: Treatment utilization/costs and work performance for persons with major depressive disorder (MDD) by severity of illness is not well documented. Methods: Using National Comorbidity Survey-Replication (2001–2002) data, US workforce respondents (n=4,465) were classified by clinical severity (not clinically depressed, mild, moderate, severe) using a standard self-rating scale [Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR)]. Outcomes included 12-month prevalence of medical services/medications use/costs and workplace performance. Treatment costs (employer's perspective) were estimated by weighing utilization measures by unit costs obtained for similar services used by MDD patients in claims data. Descriptive analysis across three severity groups generated χ2 results. Results: Using a sample of 539 US workforce respondents with MDD, 13.8% were classified mild, 38.5% moderate, and 47.7% severe cases. Mental health services usage, including antidepressants, increased significantly with severity, with average treatment costs substantially higher for severe than for mild cases both regarding mental health services ($697 vs. $388, χ2=4.4, P=.019) and antidepressants ($256 vs. $88, χ2=9.0, P=.001). Prevalence rates of unemployment/disability increased significantly (χ2=11.7, P=.003) with MDD severity (15.7, 23.3, and 31.3% for mild, moderate, and severe cases). Severely and moderately depressed workers missed more work than nondepressed workers; the monthly salary-equivalent lost performance of $199 (severely depressed) and $188 (moderately depressed) was significantly higher than for nondepressed workers (χ2=10.3, P

Objective: To understand factors driving the economic burden of major depressive disorder (MDD) patients with different treatment regimens, by evaluating the relationship between medical profiles and treatment costs. Abstract: Methods: Claims data for US privately insured employees (1999-2004) were analysed. Analysis included adult employees with ≥1 diagnosis of MDD and ≥1 prescription for specific antidepressants following a 6-month washout period. Patients were first classified into treatment pattern groups (switchers/discontinuers/maintainers/augmenters), then stratified into mutually exclusive treatment groups - nonstable, stable and intermediate - based on evidence of stability in treatment therapy. Rates of mental and physical co-morbidities, injuries/accidents, substance abuse and urgent care use were analysed across treatment pattern groups. Direct (medical/drug) costs were calculated per patient per year and disaggregated into depression- and non-depression-related components. A two-part multivariate model controlled for baseline characteristics. Costs were also estimated for patients with MDD only, patients with MDD and generalized anxiety disorder (GAD), and patients with MDD and any type of anxiety. Abstract: Results: Annual per patient adjusted costs (year 2005 values) were significantly lower among stable patients (&dollar;US6215) than among intermediate (&dollar;US7317) and nonstable patients (&dollar;US9948; p < 0.001). Stable patients also had lower depression- and non-depression-related costs. Patients with MDD and comorbid GAD or any type of anxiety had significantly higher costs than MDD-only patients. Abstract: Conclusions: Nonstability of treatment is associated with higher comorbidity rates, more urgent care use and higher total, depression- and non-depression-related direct costs. The stable group represents continuity of care and is associated with significant cost savings. Co-morbidities are associated with increased costs.

Compare treatment persistence, healthcare utilisation and costs for patients treated with escitalopram versus other SSRI/SNRIs in a real-world setting.Patients with a diagnosis for major depressive disorder (MDD) and at least one prescription for an SSRI or SNRI were identified from the Ingenix Impact Database (2002-2005). The baseline and study observation periods were defined as the 6 months before and after the index date (first date for an SSRI /SNRI pharmacy claim). Comparisons were made between patients initiated on escitalopram versus other SSRI/SNRIs using descriptive statistics and multivariate regressions.Escitalopram patients (n=10,465) had better treatment persistence compared to patients initiated on other SSRI/SNRIs (n=28,310): the hazard ratio of all discontinuation was 0.96 (95% confidence interval [CI]=0.94-0.99) for the escitalopram therapy (p=0.003), and the hazard ratio of switching to another second-generation antidepressant was 0.91 (95% CI=0.87-0.94) for the escitalopram therapy (p0.001). Escitalopram patients also had fewer inpatient service and emergency room visits. Adjusted average total all-cause healthcare costs and inpatient services costs were $839 and $405 lower in the escitalopram group (both p0.05).Escitalopram may be associated with lower healthcare utilisation and costs among adult MDD patients compared to other SSRI/SNRIs.

To compare escitalopram versus citalopram for the treatment of major depressive disorder (MDD) in geriatric patients.Administrative claims data (2003-2005) were analyzed for patients agedor =65 years with at least one inpatient claim or two independent medical claims associated with MDD diagnosis. Patients were continuously enrolled for at least 12 months, filled at least one prescription for citalopram or escitalopram and had no second generation antidepressant use during the 6-month pre-index date. Contingency table analysis and survival analysis were used to compare outcomes between the two treatment groups.Treatment persistence, hospitalization utilization, and prescription drug, medical, and total healthcare costs were analyzed. Outcomes were compared between patients initiated on escitalopram and those initiated on citalopram both descriptively and using multivariate analysis adjusting for baseline characteristics.Among 691 geriatric patients, escitalopram-treated patients (n=459) were less likely to discontinue treatment (hazard ratio [HR]=0.83, p=0.049) or switch to another second generation antidepressant (HR=0.62, p=0.001) compared to patients treated with citalopram (n=232). Patients treated with escitalopram had a significantly lower hospitalization rate (31.2% vs. 38.8%, p=0.045) and 66% fewer hospitalization days based on negative binomial regression (p0.001). While escitalopram patients had comparable prescription drug costs, they had lower total medical service costs (regression: $9748 vs. $19,208, p0.001) and lower total healthcare costs (regression: $11,434 vs. $20,601, p0.001).This study's limitations include its small sample size, short observational periods and exclusivity of indirect costs.Geriatric patients treated with escitalopram had better treatment persistence, fewer hospitalizations, and lower medical and total healthcare costs than patients treated with citalopram. Most of the cost reduction was attributable to significantly lower hospitalizations and total medical costs.

The prevalence and workplace consequences of adult attention deficit/hyperactivity disorder (ADHD) are unknown.An ADHD screen was included in a national household survey (n = 3198, ages 18-44). Clinical re-interviews calibrated the screen to diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition ADHD. Diagnoses among workers were compared with responses to the WHO Health and Work Performance Questionnaire (HPQ).A total of 4.2% of workers had ADHD. ADHD was associated with 35.0 days of annual lost work performance, with higher associations among blue collar (55.8 days) than professional (12.2 days), technical (19.8 days), or service (32.6 days) workers. These associations represent 120 million days of annual lost work in the U.S. labor force, equivalent to dollar 19.5 billion lost human capital.ADHD is a common and costly workplace condition. Effectiveness trials are needed to estimate the region of interest of workplace ADHD screening and treatment programs.

Depression imposes significant costs on sufferers, their families and care-givers, employers and insurance payers. This article summarises medical and health economics literature regarding the societal economic burden of depression and the incremental economic burden of depression sufferers in comparison with non-depressed counterparts. This substantial knowledge base probably underestimates the true economic burden of the disease because the available data and analysis techniques do not capture all of the subtle costs of this condition. Future investigation is likely to focus on the relationship between depression and comorbid conditions, the role of caregiver burdens, and the economic differences in life outcomes.

The objective of this study is to provide a comprehensive estimate of the cost of ADHD by consider ing the healthcare and work loss costs of persons with ADHD, as well as those costs imposed on their family members.Excess per capita healthcare (medical and prescription drug) and work loss (disability and work absence) costs of treated ADHD patients (ages 7 years-44 years) and their family members (under 65 years of age) were calculated using administrative claims data from a single large company; work loss costs are from disability data or imputed for medically related work loss days. Excess costs are the additional costs of patients and their family members over and above those of comparable control individuals. The excess costs of untreated individuals with ADHD and their family members were also estimated. All per capita costs were extrapolated using published prevalence and treatment rates and population data; the prevalence of persons with ADHD was based upon the literature.The total excess cost of ADHD in the US in 2000 was $31.6 billion. Of this total, $1.6 billion was for the ADHD treatment of patients, $12.1 billion was for all other healthcare costs of persons with ADHD, $14.2 billion was for all other healthcare costs of family members of persons with ADHD, and $3.7 billion was for the work loss cost of adults with ADHD and adult family members of persons with ADHD.The annual cost of ADHD in the US is substantial. Both treated and untreated persons with ADHD, as well as their family members, impose consider able economic burdens on the healthcare system as a result of this condition. While these first estimates of the cost of ADHD to the nation are suggestive of its substantial economic burden, future research needs to refine and build on this analysis, particularly in the context of a model to control for related co-morbidities. Similarly, since these results are based on data from a single company for the period 1996-1998, the analysis should be validated with more representative, current data.

Depression is a common psychiatric disorder affecting approximately 17 million Americans each year and resulting in a significant economic burden, estimated at $43-$53 billion in 1990. The cost burden of depression extends beyond the direct cost of treatment, to include the costs of lost productivity, both while at work and days absent from work, as well as lost earnings due to increased mortality and the impacts experienced by a patient's caregivers. This range of costs is discussed, in the context of the prevalence and impacts of depression and detailing the cost components of depression. We highlight that existing estimates of the cost of depression are underestimates and we conclude with areas for future research.

Background and Objective: A growing body of literature on the economics of depression concludes that this illness has an enormous impact on workplace performance. In addition to work cutback and sporadic absenteeism, the symptoms of depression also result in elevated rates of chronic absenteeism that manifest in the form of workplace disability. Design and Setting: Using a unique data source that contains the medical, pharmaceutical and disability claims of a national US manufacturer, we measured the extent of disability before and after initial treatment for major depression. Participants: 1260 employees with at least one medical or disability claim for major depression based on International Classification of Diseases, 9th edition (ICD-9) codes in 1996 or 1997. Results: We estimate that the decreased disability payments in the first 30 days following initial treatment for major depression results in employer savings totalling $US93 per patient, which can exceed the cost of treatment for a similar period of time. These disability savings do not incorporate several additional sources of likely cost savings to the employer, and thereby underestimate the workplace offsets associated with depression treatment. Additional benefits to the employer from the treatment of depression include reduced work cutback and decreased sporadic absenteeism of treated employees, reductions in some types of medical and prescription drug expenditures following appropriate depression treatment, and productivity improvements by employees serving as caregivers for treated spouses and children. Furthermore, to the extent that new pharmaceutical products offer advantages in the workplace over existing treatments for depression, the first month of such treatment will be associated with workplace savings that exceed per-patient estimates reported here for current treatment modalities. Conclusions: The findings from this analysis imply that the workplace benefits from improved functioning are substantial and may in fact exceed the usual costs of depression treatment. Thus, purely on economic rather than clinical or quality-of-life grounds, this argues in favour of more aggressive outreach to employees with symptomatic disease that results in initiation of treatment before their symptoms are allowed to persist and result in a disability claim. In this light, detection and treatment of depression in the workplace can be seen as important components of community-based disease management programmes.

We analyzed data from two national surveys to estimate the short-term work disability associated with thirty-day major depression. Depressed workers were found to have between 1.5 and 3.2 more short-term work-disability days in a thirty-day period than other workers had, with a salary-equivalent productivity loss averaging between $182 and $395. These workplace costs are nearly as large as the direct costs of successful depression treatment, which suggests that encouraging depressed workers to obtain treatment might be cost-effective for some employers.

Objective: To assess effects of antidepressant treatment compliance on health care and workplace costs. Methods: By using workplace survey data linked to two employers' health care claims, employees with depression/ antidepressant claims were categorized into noncompliant/compliant groups. Annualized costs were compared between compliance groups, for the employees with antidepressant use and a subset diagnosed with depression. Results: Among antidepressant users (N = 1224), medical costs were not statistically different for compliant versus noncompliant patients; drug costs were higher for compliant patients, primarily because of antidepressants' costs. Similar associations were observed among depressed patients (N = 488). Absenteeism costs were lower for compliant patients with antidepressant use ($3857 vs $4,907, P = 0.041) and among depressed patients ($3976 vs $5899, P = 0.047). Presenteeism costs were higher for depressed compliant patients ($19,170 vs $15,829, P = 0.011). Conclusions: Increased compliance with antidepressants is significantly associated with reduced absenteeism costs.

To compare medical and cost profiles of patients treated for depression classified by treatment pattern groups.An analysis used de-identified 1999-2004 employer claims data (n=2.9 million beneficiaries) for employees withor =1 diagnosis of major depressive disorder andor =1 antidepressant prescription, following a 6-month washout period of no antidepressant prescription. Patients were classified into switcher/discontinuer/augmenter/maintainer during Healthcare Effectiveness Data and Information Set-defined initial and subsequent treatment periods, then grouped into stable, intermediate, or non-stable treatment groups, based on stability of treatment patterns. Medical/cost profiles for 6-month pre- and 12-month post-index periods were compared descriptively, and multivariate regressions were estimated, controlling for baseline characteristics/severity markers. Cost savings reflect differences between treatment pattern groups from a current US perspective.Of the 5,225 patients meeting inclusion criteria, 60.8% were in stable, 24.5% in intermediate and 14.7% in non-stable treatment groups. No significant differences existed in medical profiles and costs between the three groups in the pre-index period. In the post-index period, stable group patients had lower costs compared to intermediate and non-stable groups. Stable group patients generated cost savings of $1,842 compared to intermediate and $5,231 compared to non-stable groups. Multivariate analysis confirmed these findings.Patients on a more stable treatment regimen yield significant cost savings compared to patients on a less stable regimen.

This study estimates the costs to society of prescription opioid analgesic (RxO) abuse in the United States.Costs associated with RxO abuse were grouped into healthcare, criminal justice, and workplace categories. Costs were estimated by either (1) a quantity method that multiplies the number of RxO abusers derived from various national surveys by the estimated per abuser cost, or (2) an apportionment method that starts with overall (ie, prescription and nonprescription) drug abuse costs for a cost component (eg, police protection) and apportions the share of costs based on the prevalence of RxO abuse relative to overall drug abuse. Medical costs in excess of those for otherwise similar nonabusers were based on an analysis of a large administrative claims database for an employed population using multivariate regression methods.A lower bound estimate of the costs of RxO abuse in the United States was 8.6 billion dollars in 2001 (or 9.5 billion dollars in 2005 dollars). Of this amount, 2.6 billion dollarswere healthcare costs, 1.4 billion dollars were criminal justice costs, and 4.6 billion dollars were workplace costs.The costs of RxO abuse represent a substantial economic burden. Rising trends of RxO abuse suggest an escalating economic and public health burden in coming years in the United States, and potentially, elsewhere.

BACKGROUND: This retrospective study compared treatment patterns and costs for patients with recognized and unrecognized bipolar disorder with those of depressed patients without a bipolar disorder claim. METHOD: Claims data for 7 large national employers covering 585,584 persons aged less than 65 years were used to identify patients diagnosed with depression and initially treated with antidepressants. Data on employees, as well as spouses and dependents, for the period 1998 to mid-2001 were used. Patients were identified as bipolar based on the criteria of a bipolar diagnosis claim (ICD-9 codes: 296.0, 296.1, 296.4-296.8) and/or a mood stabilizer prescription claim. Of the patients identified as bipolar, unrecognized bipolar disorder (unrecognized-BP) patients met the criteria after antidepressant initiation, while recognized bipolar disorder (recognized-BP) patients met the criteria at or before initiation. The remaining patients in the sample were non-bipolar depressed (non-BP) patients. Outcome measures included treatment patterns and monthly medical costs in the 12 months subsequent to initiation of antidepressant treatment. RESULTS: Of the 9009 patients treated for depression with antidepressants, there were 8383 non-BP patients (93.1%), 293 recognized-BP patients (3.3%), and 333 unrecognized-BP patients (3.7%). Use of combination therapies varied among the non-BP (11%), unrecognized-BP (32%), and recognized-BP patients (44%) (all pairwise p

Background: While there is a growing literature on various aspects of depression in women, there is little research about the economic cost of depression in women. This analysis focuses on the direct and indirect cost to employers of female compared to male employees treated for depression, and their service utilization patterns. Methods: We used a claims database from a national, Fortune 100 company to analyze the direct (medical and prescription drug) and indirect (disability and illness-related work absence) costs to an employer for female and male beneficiaries with depression. Results: In 1998, the average female employee with depression cost this company $9265 compared to $8502 for male employees with depression. These women had significantly greater work absence costs which led to higher total costs than men, even though their medical costs were lower than those of comparable men. Limitations: Our analysis of the indirect costs associated with depressed female and male employees is limited to the costs of disability and sporadic illness-related work absences. The data available from this one employer did not allow accounting for the cost of reduced productivity while at work. Conclusions: We recommend that employers consider programs to improve the management of individuals with depression, in particular women. Also, further research is necessary to encourage the medical community to be more sensitive to the symptoms of depression in women.

Background: Major depressive disorder (MDD) is a debilitating condition with significant economic consequences. Conservative estimates indicate that between 10% and 20% of all individuals with MDD are treatment resistant. The objectives for this study were ( I ) to use current treatment strategies identified in the literature to evaluate the validity of studying treatment-resistant depression (TRD) using claims data and (2) to estimate cost differences between TRD-likely and TRD-unlikely patients identified by use of treatment patterns. Method: The data source consisted of medical, pharmaceutical, and disability claims from a Fortune 100 manufacturer for 1996 through 1998 (N = 125,242 continuously enrolled beneficiaries between the ages of 18 and 64 years). The sample included individuals with medical or disability claims for MDD (N MDD = 4186). A treatment pattern algorithm was applied to classify adult MDD patients into TRD-likely (N TRI ) = 487) and TRD-unlikely groups. Resource utilization and costs were compared among TRD-likely and TRD-unlikely patients and a random sample of average beneficiaries (i.e., 10% of all beneficiaries) for 1998. Results: Consistent with the epidemiologic literature, the algorithm classified 12% of the MDD sample as TRD-likely. Mean annual costs were $10,954 for TRD-likely patients, $5025 for TRD-unlikely patients, and $3006 for average beneficiaries. TRD-likely patients used almost twice as many medical services as did TRD-unlikely patients and incurred significantly greater indirect costs (p

Over the past decade, psychiatric disorders have increasingly been regarded as serious public health concerns, with debilitating symptoms as well as high social and economic costs to patients, caregivers, third party payers and society. In this article, we review findings from recent research on psychiatric disorders, while providing a framework for assessing their pharmacoeconomic impact. In particular, we consider the prevalence of psychiatric disorders, their far-reaching impacts, and their associated treatment patterns. These categories present a starting point for analysing the pharmacoeconomic consequences of psychiatric disorders and underlie an expert opinion in this context

This article discusses the impact of depression on work productivity and the potential for improved work performance associated with effective treatment. We undertook a review of the literature by means of a computer search using the following key terms: cost of illness, work loss, sickness absence, productivity, performance, and disability. Published works were considered in four categories: (1) naturalistic cross-sectional studies that found greater self-reported work impairment among depressed workers; (2) naturalistic longitudinal studies that found a synchrony of change between depression and work impairment; (3) uncontrolled treatment studies that found reduced work impairment with successful treatment; and (4) controlled trials that usually, but not always, found greater reduction in work impairment among treated patients. Observational data suggest that productivity gains following effective depression treatment could far exceed direct treatment costs. Randomized effectiveness trials are needed before we can conclude definitively that depression treatment results in productivity improvements sufficient to offset direct treatment costs.

Background We assess the annual economic burden of anxiety disorders in the United States from a societal perspective. Method Using data from the National Comorbidity Study, we applied multivariate regression techniques to calculate the costs associated with anxiety disorders, after adjusting for demographic characteristics and the presence of comorbid psychiatric conditions. Based on additional data, in part from a large managed care organization, we estimated a human capital model of the societal cost of anxiety disorders. Results We estimated the annual cost of anxiety disorders to be approximately $42.3 billion in 1990 in the United States, or $1542 per sufferer. This comprises $23.0 billion (or 54% of the total cost) in nonpsychiatric medical treatment costs, S13.3 billion (31%) in psychiatric treatment costs, $4.1 billion (10%) in indirect workplace costs, $1.2 billion (3%) in mortality costs, and $0.8 billion (2%) in prescription pharmaceutical costs. Of the $256 in workplace costs per anxious worker, 88% is attributable to lost productivity while at work as opposed to absenteeism. Posttraumatic stress disorder and panic disorder are the anxiety disorders found to have the highest rates of service use. Other than simple phobia, all anxiety disorders analyzed are associated with impairment in workplace performance. Conclusion Anxiety disorders impose a substantial cost on society, much of which may be avoidable with more widespread awareness, recognition, and appropriate early intervention.

There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys.To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population.Direct interviews.Households in the continental United States.A nationally representative sample of 9282 English-speaking adults (agedor=18 years).Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment.Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings.This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.