Depression and substance abuse and dependency in relation to current smoking status and frequency of smoking among nondaily and daily smokers

BACKGROUND AND OBJECTIVES

Daily smoking rates are decreasing while intermittent or nondaily smoking rates are increasing. Little is known about the association of depression, alcohol abuse and dependence, and illicit drug abuse and dependence with different patterns of smoking, particularly nondaily smoking. Thus, we examined these relationships among current smokers versus nonsmokers and among those who smoke daily versus less frequently.

METHODS

We conducted a secondary analysis of 37,897 adults who participated in the 2008 National Survey on Drug Use and Health. We developed logistic regression models examining predictors of (i) current smoking and (ii) number of days smoking per month (1-10 days, 11-29 days, and ≥30 days) among current smokers, focusing on past-year major depression, alcohol abuse and dependence, and illicit drug abuse and dependence.

RESULTS

Compared to nonsmokers, current smokers more frequently reported a major depressive episode (p < .001), alcohol dependence (p < .001) and abuse (p < .001), and illicit drug dependence (p < .001) and abuse (p < .001), controlling for sociodemographics. Among current smokers, greater smoking frequency was associated with illicit drug dependence (p = .004), but lower likelihood of alcohol dependence (p = .01), alcohol abuse (p = .01), and illicit drug abuse (p = .01).

CONCLUSIONS

Although depression and substance use were associated with greater likelihood of smoking, most measures were inversely associated with frequency of smoking. Thus, it is important to examine underlying mechanisms contributing to these counterintuitive findings in order to inform intervention approaches.

SCIENTIFIC SIGNIFICANCE

With increased rates of nondaily smoking, developing a greater understanding about the mental health correlates related to this pattern of smoking is critical.

Geography and the Medicaid mental health care infrastructure: implications for health care reform

IMPORTANCE

Medicaid is the largest payer of mental health (MH) care in the United States, and this role will increase among states that opt into the Medicaid expansion. However, owing to the dearth of MH care providers who accept Medicaid, expanded coverage may not increase access to services. Facilities that provide specialty outpatient MH services and accept Medicaid compose the backbone of the community-based treatment infrastructure for Medicaid enrollees. For states that opt into the expansion, it is important to understand which local communities may face the greatest barriers to access these facilities.

OBJECTIVE

To examine the availability of outpatient MH facilities that accept Medicaid across US counties and whether specific types of communities are more likely to lack this infrastructure.

DESIGN, SETTING, AND PARTICIPANTS

Data from the 2008 National Survey of Mental Health Treatment Facilities and Area Resource File were merged. A generalized ordered logistic regression with state fixed effects was estimated to examine determinants of accessibility of these facilities. Covariates included the percentages of residents who are black, Hispanic, living in poverty, and living in a rural area.

MAIN OUTCOMES AND MEASURES

An ordered variable assessed whether a county had no access to outpatient MH facilities that accept Medicaid, intermediate access to these facilities (ie, ≥1 facility, but not top quintile of facility to Medicaid enrollee per capita ratio), or high access (ie, top quintile of facility to Medicaid enrollee per capita ratio).

RESULTS

More than one-third of counties do not have any outpatient MH facilities that accept Medicaid. Communities with a larger percentage of residents who are black (marginal effect [ME] = 3.9%; 95% CI, 1.2%-6.6%), Hispanic (ME = 4.8%; 95% CI, 2.3%-7.4%), or living in a rural area (ME = 27.9%; 95% CI, 25.3%-30.4%) are more likely to lack these facilities.

CONCLUSIONS AND RELEVANCE

Many communities may face constraints on the MH safety-net system as Medicaid is expanded, especially rural communities and communities with a large percentage of black or Hispanic residents.

Health insurance and treatment of adolescents with co-occurring major depression and substance use disorders

OBJECTIVE

The goals of this study were to identify treatment rates among adolescents with co-occurring major depressive episode (MDE) and substance use disorder (SUD), and to examine the role of health insurance in the treatment of these disorders.

METHOD

Seven years of cross-sectional data (2004-2010) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 2,111 adolescents who had both a past-year MDE and SUD and whose insurance status was known. The associations of public and private insurance with MDE and SUD treatment were examined using multinomial logistic regressions that controlled for health status and sociodemographic variables.

RESULTS

Less than one-half (48%) of adolescents received any form of MDE treatment in the past year, and only 10% received any form of SUD treatment. Only 16% of adolescents who received MDE treatment also received SUD treatment. Relative to no insurance, public insurance was associated with an increased likelihood of receiving MDE treatment alone, but not with an increased likelihood of receiving both MDE and SUD treatment. Involvement in the criminal justice system was the major factor affecting the likelihood that an adolescent would receive both MDE and SUD treatment, as opposed to either no treatment or treatment for MDE alone.

CONCLUSIONS

Exceptionally low rates of SUD treatment were observed in this high-risk sample. Study findings highlight a missed opportunity to assess and to treat SUD among adolescents with co-occurring MDE and SUD who have received some form of MDE treatment in the past year.

Advancing the adoption, integration and testing of technological advancements within existing care systems

OBJECTIVE

This manuscript reviews the work on uptake and dissemination of health information technologies in mental health populations and settings, with the goal of informing the future research agenda.

METHODS

We reviewed both the formal and "grey" literature describing the rates and correlates of uptake for electronic health records (EHRs) and personal health records (PHRs) for general and specialty mental health settings.

RESULTS

Rates of uptake and use of EHRs and PHRs are low in general medical settings, and the limited evidence suggests even lower rates for specialty mental health settings. Many of the patient, provider and system-level characteristics associated with lower rates of use in general populations would be expected to be exacerbated in mental health settings.

CONCLUSIONS

The findings suggest a need to better understand both the causes and strategies for overcoming barriers to uptake of health information technology (HIT) in mental health settings. Observational studies could help to better elucidate the barriers to adoption of HIT that are unique or disproportionate in mental health populations. Implementation science studies are needed to better identify strategies for addressing these barriers and optimizing uptake of mental health HIT interventions.

Change in health insurance coverage in Massachusetts and other New England States by perceived health status: potential impact of health reform

OBJECTIVES

We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.

METHODS

We used 2003-2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.

RESULTS

The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states--from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.

CONCLUSIONS

On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.

Addressing public stigma and disparities among persons with mental illness: the role of federal policy

Stigma against mental illness is a complex construct with affective, cognitive, and behavioral components. Beyond its symbolic value, federal law can only directly address one component of stigma: discrimination. This article reviews three landmark antidiscrimination laws that expanded protections over time for individuals with mental illness. Despite these legislative advances, protections are still not uniform for all subpopulations with mental illness. Furthermore, multiple components of stigma (e.g., prejudice) are beyond the reach of legislation, as demonstrated by the phenomenon of label avoidance; individuals may not seek protection from discrimination because of fear of the stigma that may ensue after disclosing their mental illness. To yield the greatest improvements, antidiscrimination laws must be coupled with antistigma programs that directly address other components of stigma.

Students left behind: the limitations of university-based health insurance for students with mental illnesses

A growing trend in college and university health care is the requirement that students demonstrate proof of health insurance prior to enrollment. An increasing number of schools are contracting with insurance companies to provide students with school-based options for health insurance. Although this is advantageous to students in some ways, tying health insurance coverage to school enrollment can leave students vulnerable when they are most in need of help. Students whose health insurance is contingent upon their enrollment face significant lapses in coverage when they are required to leave school. This is especially challenging for students with mental illnesses whose treatment needs often go unmet in the absence of that coverage. The limitations in this system must be addressed as an increasing number of universities and students opt for university-based health insurance plans.

Racial/ethnic differences in treatment for substance use disorders among U.S. adolescents

OBJECTIVE

This study examined differences in treatment rates for substance use disorders (SUD) among adolescents of white, black, Hispanic, Asian, Native American/Alaska Native, and Native Hawaiian/Pacific Islander race/ethnicity.

METHOD

Eight years of cross-sectional data (2001-2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 144,197 adolescents (aged 12-17 years); 12,634 adolescents were identified with SUD in the previous year. Weighted probit regressions were estimated with year fixed effects to examine whether racial/ethnic minorities had lower rates of treatment in any setting, in medical settings (i.e., hospital, rehabilitation facility, mental health clinic, and/or doctor's office), and in self-help programs. Initial models controlled for demographics and health status. Additional models further adjusted for family income and health insurance status.

RESULTS

Among adolescents with SUD, unadjusted treatment rates ranged from 8.4% among blacks to 23.5% among Native Hawaiian/Pacific Islanders. After adjusting for demographics and health status, blacks (RD = -3.9%, 95% CI = -6.4%, -1.3%) and Hispanics (RD = -2.3%, 95% CI = -4.1%, -0.4%) were significantly less likely to receive SUD treatment than whites (adjusted treatment rate 10.7%). These differences were exacerbated after adjusting for family income and insurance status. Lower treatment rates for black and Hispanic adolescents persisted when examining SUD treatment rates in medical settings and self-help programs. Treatment rates for other racial/ethnic groups did not generally differ from whites.

CONCLUSION

Results highlight exceptionally low treatment rates for SUD among all adolescents, with blacks and Hispanics experiencing the lowest treatment rates across all racial/ethnic groups.

Budget impact and sustainability of medical care management for persons with serious mental illnesses

OBJECTIVE

The authors assessed the 2-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings.

METHOD

A total of 407 psychiatric outpatients with serious mental illnesses were randomly assigned to usual care or to a medical care manager who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, as well as costs from both the health system and managerial perspectives.

RESULTS

Sustained improvements were observed in the intervention group in quality of primary care preventive services, quality of cardiometabolic care, and mental health-related quality of life. From a health system perspective, by year 2, the mean per-patient total costs for the intervention group were $932 (95% CI=-1,973 to 102) less than for the usual care group, with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e., revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in this study had Medicaid, the program was not sustainable after grant funding ended.

CONCLUSIONS

The positive long-term outcomes and favorable cost profile provide evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the program's financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing evidence-based interventions such as the one examined in this study.

Opening doors to recovery: a novel community navigation service for people with serious mental illnesses

This column describes Opening Doors to Recovery in Southeast Georgia, a partnership between public agencies, a private corporation, a not-for-profit organization, and an academic institution. Teams of community navigation specialists that include a licensed mental health professional, a family member of an individual with a serious mental illness, and a peer with lived experience in recovery seek to enhance participants' community integration, support them in developing a meaningful day, ensure access to adequate treatment, and facilitate stable housing, improved relationships, and desired vocational, volunteer, or educational activities.

Psychological distress severity of adults reporting receipt of treatment for mental health problems in the BRFSS

OBJECTIVE

Although effective mental health treatments exist, few population data are available on treatment receipt by persons with psychological distress. This study aimed to understand the association between symptoms and treatment receipt with data from the U.S Behavioral Risk Factor Surveillance System (BRFSS) survey.

METHODS

In the 2007 survey, psychological distress was assessed with the Kessler-6 scale, and respondents were asked about receipt of mental health treatment. Data from 197,914 respondents were analyzed.

RESULTS

In the overall population 87.5% of respondents reported no psychological distress, 8.5% mild to moderate psychological distress, and 3.9% serious psychological distress. Those with serious distress were nearly ten times as likely to receive treatment (adjusted odds ratio=9.58, 95% confidence interval=8.53-10.75) as those with no distress. One in ten persons (10.7%) in the study population reported receiving treatment.

CONCLUSIONS

Distinct U.S. subpopulations exist by treatment and symptom status. Better understanding of all these groups is essential for improving population-based mental health care.

Antidepressant use in the absence of common mental disorders in the general population

OBJECTIVE

To examine the prevalence of antidepressant use in the absence of lifetime mental disorders and to examine sociodemographic correlates, indicators of need (hospitalization, suicidal behavior, perceived need, subthreshold disorders, disability, traumatic events), and antidepressant characteristics of such use.

METHOD

Data came from the Collaborative Psychiatric Epidemiologic Surveys (N = 20,013), a nationally representative cross-sectional sample of community-dwelling adults in the United States. Sociodemographic correlates and indicators of need were examined as predictors of past-year use of antidepressants in the absence of a lifetime DSM-IV diagnosis as assessed by the World Mental Health Composite Diagnostic Interview. The surveys were conducted between 2001 and 2003.

RESULTS

Among individuals who took an antidepressant in the past year (n = 1,441), 396 (26.3%) did not meet criteria for any lifetime diagnosis assessed. Respondents taking antidepressants in the absence of a lifetime diagnosis tended to be older, white, and female. All indicators of need except past-year suicidal behavior were significant predictors (adjusted odds ratios ranging from 2.12 to 14.22, P < .001), with 89% of individuals taking antidepressants in the absence of a lifetime diagnosis endorsing at least 1 indicator of need. Individuals taking antidepressants in the absence of a DSM-IV disorder were more likely to have been prescribed these medications by family physicians or other doctors compared to psychiatrists.

CONCLUSIONS

These results suggest that antidepressant use among individuals without psychiatric diagnoses is common in the United States and is typically motivated by other indicators of need. These findings have important implications for the delivery of medical and psychiatric care and psychiatric nosology.

Racial/ethnic differences in mental health service use among adolescents with major depression

OBJECTIVE

Little is known about racial/ethnic differences in the receipt of treatment for major depression in adolescents. This study examined differences in mental health service use in non-Hispanic white, black, Hispanic, and Asian adolescents who experienced an episode of major depression.

METHOD

Five years of data (2004-2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 7,704 adolescents (12-17 years old) diagnosed with major depression in the past year. Racial/ethnic differences were estimated with weighted probit regressions across several measurements of mental health service use controlling for demographics and health status. Additional models assessed whether family income and health insurance status accounted for these differences.

RESULTS

The adjusted percentages of blacks (32%), Hispanics (31%), and Asians (19%) who received any treatment for major depression were significantly lower than those of non-Hispanic whites (40%; p < .001). Black, Hispanic, and Asian adolescents were also significantly less likely than non-Hispanic whites to receive prescription medication for major depression, to receive treatment for major depression from a mental health specialist or medical provider, and to receive any mental health treatment in an outpatient setting (p < .01). These differences persisted after adjusting for family income and insurance status.

CONCLUSION

Results indicated low rates of mental health treatment for major depression in all adolescents. Improving access to mental health care for adolescents will also require attention to racial/ethnic subgroups at highest risk for non-receipt of services.

Patient-level predictors and clinical correlates of duration of untreated psychosis among hospitalized first-episode patients

OBJECTIVE

Duration of untreated psychosis (DUP) has been associated with poor early course outcomes of nonaffective psychotic disorders; however, less is known about predictors of DUP. This study examined patient-level predictors of DUP and clinical correlates of both DUP and duration of untreated illness (DUI), both of which have been implicated as prognostic indicators.

METHOD

Participants included 109 first-episode patients hospitalized in 3 public-sector inpatient psychiatric units serving an urban, socially disadvantaged, predominantly African American community. DUP, DUI, and a number of clinical and psychosocial variables were measured using standardized methods. Patients were diagnosed with schizophrenia and related psychotic disorders according to the Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

The median DUP and DUI were 22.3 and 129.9 weeks, respectively. Survival analyses revealed that, at any given time point, patients not living with family members were, on average, about 1.5 times as likely to be hospitalized as those living with family when controlling for mode of onset of psychosis. Patients not living in poverty were, on average, about 1.6 times as likely to be hospitalized as those living in poverty when controlling for mode. A greater burden of negative symptoms was associated with longer DUP (r = 0.23, P = .02), and poorer insight was associated with longer DUI (r = -0.24, P = .01). Longer DUP and DUI were associated with diverse adverse clinical characteristics, such as greater impairment in global functioning, poorer social functioning, and more psychosocial problems.

CONCLUSIONS

There is a need for early intervention efforts to be directed to families (and their loved ones who live with them with emerging psychotic disorders or frank untreated psychotic syndromes), particularly families facing major socioeconomic challenges.

Findings of a U.S. national cardiometabolic screening program among 10,084 psychiatric outpatients

OBJECTIVE

A national cardiometabolic screening program for patients in a variety of public mental health facilities, group practices, and community behavioral health clinics was funded by Pfizer Inc. between 2005 and 2008.

METHODS

A one-day, voluntary metabolic health fair in the United States offered patients attending public mental health clinics free cardiometabolic screening and same-day feedback to physicians from a biometrics testing third party that was compliant with the Health Insurance Portability and Accountability Act.

RESULTS

This analysis included 10,084 patients at 219 sites; 2,739 patients (27%) reported having fasted for over eight hours. Schizophrenia or bipolar disorder was self-reported by 6,233 (62%) study participants. In the overall sample, the mean waist circumference was 41.1 inches for men and 40.4 inches for women; 27% were overweight (body mass index [BMI] 25.0-29.9 kg/m(2)), 52% were obese (BMI >or=30.0 kg/m(2)), 51% had elevated triglycerides (>or=150 mg/dl), and 51% were hypertensive (>or=130/85 mm Hg). In the fasting sample, 52% had metabolic syndrome, 35% had elevated total cholesterol (>or=200 mg/dl), 59% had low levels of high-density lipoprotein cholesterol (<40 mg/dl for men or <50 mg/dl for women), 45% had elevated triglycerides (>or=150 mg/dl), and 33% had elevated fasting glucose (>or=100 mg/dl). Among the 1,359 fasting patients with metabolic syndrome, 60% were not receiving any treatment. Among fasting patients who reported treatment for specific metabolic syndrome components, 33%, 65%, 71%, and 69% continued to have elevated total cholesterol, low levels of high-density lipoprotein, high blood pressure, and elevated glucose levels, respectively.

CONCLUSIONS

The prevalence of metabolic syndrome and cardiometabolic risk factors, such as overweight, hypertension, dyslipidemia, and glucose abnormalities, was substantial and frequently untreated in this U.S. national mental health clinic screening program.

Quality of diabetes care for underserved patients with and without mental illness: site of care matters

OBJECTIVE

This study assessed whether practice setting (outpatient primary care or emergency care) influenced whether patients with mental illness received the same quality of diabetes preventive care as patients without mental illness.

METHODS

Cross-sectional analyses of administrative claims data from 8,817 diabetic patients with (N=908) and without (N=7,909) mental illness seen in either the emergency or the outpatient setting of a safety-net health system were used to examine receipt of diabetes-related preventive care. Outcomes included receipt of dilated eye examinations and testing of high-density lipoprotein (HDL), low-density lipoprotein (LDL), glycosylated hemoglobin (HbA1c), and nephropathy.

RESULTS

Receipt of testing for HDL, LDL, and nephropathy were comparable for patients with and without mental illness (overall rates of 36%, 33%, and 34%); however, persons with mental illness were significantly less likely to be tested for HbA1c (48% versus 52%; p=.043) and to have an eye exam (40% versus 45%; p=.006). Patients with mental illness had twice as many visits in the emergency setting (mean number of visits, 7.0 ± 12.0 versus 2.8 ± 6.0; p<.001), and all diabetic patients seen only in the emergency setting, regardless of mental illness status, received fewer diabetes preventive services than those who were ever seen in an outpatient setting (p<.001).

CONCLUSIONS

In this safety-net setting, site of care appeared to be more important than mental illness diagnosis as a determinant of quality of diabetes care. Persons with mental illness may obtain similar potential advantages as those without mental illness from better coordination with outpatient medical care.

Small area variation and geographic and patient-specific determinants of metabolic testing in antipsychotic users

PURPOSE

The American Diabetes Association and American Psychiatric Association recommend metabolic monitoring for all patients using second-generation antipsychotic (SGA) drugs. We estimated glucose and lipid testing rates among SGA-users from three state Medicaid programs and investigated small area variation and patient and geographic determinants of testing.

METHODS

A retrospective new-user cohort study using Medicaid claims data from California, Missouri, and Oregon was conducted among 30,563 patients in 207 counties starting SGA medication September 2004-December 2005. Adjusted odds ratios for state, county, and patient factors associated with testing were calculated from multivariable hierarchical logistic regression models.

RESULTS

Mean 6-month testing rates were 51.6% (glucose) and 26.2% (lipids). Screening rates were positively associated with the number of Type 2 diabetes risk factors (RF) present: glucose -39% (0 RF) to 82% (5 RF); lipids -13% (0 RF) to 66% (5 RF). A four-fold difference in glucose testing rates (21-85%) and a greater than six-fold difference in lipid testing rates (0-62%) were observed between counties. In the adjusted regression models, age, cardiometabolic co-morbidity (diabetes, dyslipidemia), serious mental illness, persistent use of SGAs, and frequency of non-psychiatric medical office visits were significant determinants of glucose and lipid testing. Lipid testing was more likely for children and adults in California, as was glucose testing for children.

CONCLUSIONS

Glucose and lipid testing among SGA-users varied significantly between states, counties, and by patient characteristics. More effort is needed to understand provider and system reasons for testing disparities in order to inform risk management quality improvement interventions.

Health care reform and care at the behavioral health--primary care interface

The historic passage of the Patient Protection and Affordable Care Act in March 2010 offers the potential to address long-standing deficits in quality and integration of services at the interface between behavioral health and primary care. Many of the efforts to reform the care delivery system will come in the form of demonstration projects, which, if successful, will become models for the broader health system. This article reviews two of the programs that might have a particular impact on care on the two sides of that interface: Medicaid and Medicare patient-centered medical home demonstration projects and expansion of a Substance Abuse and Mental Health Services Administration program that colocates primary care services in community mental health settings. The authors provide an overview of key supporting factors, including new financing mechanisms, quality assessment metrics, information technology infrastructure, and technical support, that will be important for ensuring that initiatives achieve their potential for improving care.