Psychiatric morbidity and physician visits: lessons from Ontario

A Longitudinal Analysis of Discrete Negative Emotions and Health-Services Use in Elderly Individuals

Objective: To test the hypothesis that everyday, discrete negative emotions—anger, frustration, sadness, and fear—relate to health-service use in later life. Method: Community-dwelling adults ( n= 345) ages 72 to 99 were interviewed about the frequency of recently experienced emotions. Physician visits and hospital admissions in the subsequent 2 years were outcomes. Covariates included prior use of health services, chronic illness, functional status, and demographics. Results: Age, education, and gender moderated relations between negative emotions and health care use. More frustration was associated with fewer physician visits among older individuals. Sadness was associated with more hospital admissions for women. Among those with more education, frequent anger was associated with more physician visits. Projected effects of negative emotions resulted in increases in health-service use, ranging from 18% to 33%. Discussion: The interactions indicate the importance of negative emotions and the larger social and developmental context in health care services use among elderly individuals.

Spontaneous reports of emotional upset and health care utilization among veterans with posttraumatic stress disorder after receiving a potentially upsetting survey

This study assessed the effects of a potentially distressing mailed survey on the emotional well-being and health care utilization (HCU) of 4,918 male and female veterans who applied for posttraumatic stress disorder disability benefits. Content analysis of spontaneous comments, in combination with analysis of subjects' HCU before and after receipt of the survey, suggested that spontaneously disclosed episodes of emotional upset were rare. In general, surveyed veterans' HCU decreased after receipt of the survey.

Racial disparities in VA service connection for posttraumatic stress disorder disability

BACKGROUND

"Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access.

OBJECTIVES

To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status.

RESEARCH DESIGN

Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample.

SETTING AND SUBJECTS

The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998.

RESULTS

A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003).

CONCLUSION

Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.

Socio-economic differences in psychiatric in-patient care

OBJECTIVE

We seek to investigate socio-economic differences in psychiatric in-patient care regarding admission, treatment and outcome.

METHOD

This study is undertaken on a comprehensive and exhaustive psychiatric case register of all psychiatric in-patient care carried out in Belgium in 1997 and 1998 (n=144 754).

RESULTS

Lower socio-economic groups were more likely to be compulsorily admitted, to be cared for in a non-teaching or psychiatric hospital, to be admitted in a hospital with unexpectedly long average length of stay and to be admitted to a ward with a more severe case-mix. They were less likely to receive antidepressants and psychotherapies. The improvements in functioning and in symptoms were also less favourable for these groups. The lowest group had a higher risk of dying in the hospital.

CONCLUSION

Psychiatric in-patient care is associated with moderate socio-economic differences in access, treatment and outcome. Further research is needed to clarify the causes of such disparities.

Variability and predictors of mental disorder rates and medical practitioner responses across Australian general practices

OBJECTIVE

To determine the variation in prevalence of common mental disorders and general practitioner (GP) responses across Australian general practices, and to identify practice characteristics that predict these rates.

DESIGN

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46515 ambulatory care patients attending 386 GPs.

MAIN OUTCOME MEASURES

Practice-based prevalence of mental disorders (based on patient-reported symptoms) and GP-reported rates of psychological diagnoses and treatment (median and range, excluding the upper and lower 10% of practices); practice characteristics (patient, doctor and organisational) that predict prevalences and rates, determined by multiple regression analysis.

RESULTS

Even after omitting the upper and lower 10% of practices, there were large variations between practices in prevalence of common mental disorders (range, 39% to 59% of patients; median, 48%), and substance misuse (range, 3%-13%; median, 7%). There were also large variations between practices in rates at which GPs made psychological diagnoses in each practice (range, 12%-51%; median, 27%), judged patients to be at risk to self or others (range, 6%-54%; median, 23%), provided psychological treatments (range, 8%-41%; median, 22%) and referred patients to specialist services (range, 1%-10%; median, 4%). Practice-based rates of disorders and GP responses were predicted not only by sociodemographic characteristics of patients in each practice (eg, mean age or proportion of unemployed people), but also by doctor characteristics (eg, age and sex) and practice organisation characteristics (eg, urban versus regional or rural location).

CONCLUSION

We identified patient, GP and practice characteristics that predict rates of mental disorder and treatments provided. These could be used to guide mental health service reform in general practice and assist with targeting relevant education and practice support programs.

Depressive symptoms, health promotion, and health risk behaviors

OBJECTIVES

To assess the relationships between history of depressive symptoms and smoking, alcohol consumption, dietary changes, attempts to lose weight or increase exercise, use of health services, and the likelihood of receiving influenza and pneumonia vaccinations, mammograms, and Pap tests.

METHODS

A survey of randomly sampled members of a large health maintenance organization (n = 5841).

RESULTS

Individuals with past depressive symptoms were more likely to smoke cigarettes (despite making more attempts to quit smoking); to drink more alcohol; to attempt to lose weight, increase exercise, reduce fat intake, increase fiber intake; and, for women, to have a mammogram.

CONCLUSIONS

Individuals with histories of depressive symptoms engage in more positive and negative health behaviors. Additionally, their increased service use provides opportunities to achieve positive health changes and improve treatment outcomes.

PTSD and utilization of medical treatment services among male Vietnam veterans

This study investigated the effect of posttraumatic stress disorder (PTSD) on help-seeking for physical problems. Merging two large data sets resulted in a sample of 1773 male Vietnam veterans from white, black, Hispanic, Native Hawaiian, and Japanese American ethnic groups. Predictors of utilization included PTSD, other axis I disorders, and substance abuse. In analyses that adjusted only for age, PTSD was related to greater utilization of recent and lifetime VA medical services, and with recent inpatient care from all sources. Further analysis showed that the increased utilization associated with PTSD was not merely due to the high comorbidity between PTSD and other axis I disorders. The uniqueness of the association between PTSD and medical utilization is discussed in terms of somatization and physical illness.