The Mode Effect of Web-Based Surveying on the 2018 U.S. Health and Retirement Study Measure of Cognitive Functioning

OBJECTIVES

Measuring cognition in an aging populabtion is a public health priority. A move towards survey measurement via the web (as opposed to phone or in-person) is cost-effective but challenging as it may induce bias in cognitive measures. We examine this possibility using an experiment embedded in the 2018 wave of data collection for the U.S. Health and Retirement Study (HRS).

METHODS

We utilize techniques from multiple group item response theory to assess the effect of survey mode on performance on the HRS cognitive measure. We also study the problem of attrition by attempting to predict dropout and via approaches meant to minimize bias in subsequent inferences due to attrition.

RESULTS

We find evidence of an increase in scores for HRS respondents who are randomly assigned to the web-based mode of data collection in 2018. Web-based respondents score higher in 2018 than experimentally matched phone-based respondents, and they show much larger gains relative to 2016 performance and subsequently larger declines in 2020. The differential in favor of web-based responding is observed across all items, but is most pronounced for the Serial 7 task and numeracy items. Due to the relative ease of the web-based mode, we suggest a cutscore of 12 being used to indicate CIND (cognitively impaired but not demented) status when using the web-based version rather than 11.

DISCUSSION

The difference in mode may be nonignorable for many uses of the HRS cognitive measure. In particular, it may require reconsideration of some cutscore-based approaches to identify impairment.

Changes in Health Care Access and Utilization for Low-SES Adults Aged 51-64 Years After Medicaid Expansion

OBJECTIVES

Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults aged 51-64 years has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults aged 51-64 years before and after the ACA Medicaid expansion.

METHODS

Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N = 2,088 noninstitutionalized low-education adults aged 51-64 years (n = 633 in Medicaid expansion states, n = 1,455 in nonexpansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, and private), access (usual source of care, difficulty finding a physician, foregone care, cost-related medication nonadherence, and out-of-pocket costs), utilization (outpatient visit and hospitalization), and health status.

RESULTS

Low-education adults aged 51-64 years had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in nonexpansion states, DID +7.4 pp, p = .001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in nonexpansion states, DID +10.4 pp, p = .003) in Medicaid expansion compared with nonexpansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in nonexpansion states (+3.6 pp in expansion states, +11.0 pp in nonexpansion states, DID -7.5 pp, p = .006). There were no other significant differences in access, utilization, or health trends between expansion and nonexpansion states.

DISCUSSION

After Medicaid expansion, low-education status adults aged 51-64 years were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.

CHANGES IN HEALTH CARE UTILIZATION FOR LOW-SES ADULTS NEAR RETIREMENT AFTER THE ACA MEDICAID EXPANSION

Low-SES Americans approaching retirement are experiencing rising morbidity and mortality. We examined longitudinal changes in health care access, utilization, and health for low-SES adults age 55-64 before (2010-2012) and after (2014-2016) ACA Medicaid expansion using the HRS. With a longitudinal difference-in-differences (DID) approach adjusting for demographics and the complex survey design, we found that low-SES adults age 55-64 had increased rates of Medicaid coverage (+10.7 percentage points [pp] in expansion states, +3.4 pp in non-expansion states, DID +7.3 pp) and increased likelihood of hospitalizations (+9.9 pp in expansion states, -1.2 pp in non-expansion states, DID +11.1 pp) in Medicaid expansion compared with non-expansion states. There were no other significant differences in access, utilization or health trends between expansion and non-expansion states. After Medicaid expansion, low-SES adults age 55-64 were more likely to be hospitalized, suggesting poorer baseline access to chronic disease management and associated pent-up demand for health care services.

The Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Study Design and Methods

INTRODUCTION

The Harmonized Cognitive Assessment Protocol (HCAP) Project is a substudy within the Health and Retirement Study (HRS), an ongoing nationally representative panel study of about 20,000 adults aged 51 or older in the United States. The HCAP is part of an international research collaboration funded by the National Institute on Aging to better measure and identify cognitive impairment and dementia in representative population-based samples of older adults, in the context of ongoing longitudinal studies of aging in high-, middle-, and low-income countries around the world.

METHODS

The HCAP cognitive test battery was designed to measure a range of key cognitive domains affected by cognitive aging (including attention, memory, executive function, language, and visuospatial function) and to allow harmonization and comparisons to other studies in the United States and around the world. The HCAP included a pair of in-person interviews, one with the target HRS respondent (a randomly selected HRS sample member, aged 65+) that lasted approximately 1 h and one with an informant nominated by the respondent that lasted approximately 20 min. The final HRS HCAP sample included 3,496 study subjects, representing a 79% response rate among those invited to participate.

CONCLUSION

Linking detailed HCAP cognitive assessments to the wealth of available longitudinal HRS data on cognition, health, biomarkers, genetics, health care utilization, informal care, and economic resources and behavior will provide unique and expanded opportunities to study cognitive impairment and dementia in a nationally representative US population-based sample. The fielding of similar HCAP projects in multiple countries around the world will provide additional opportunities to study international differences in the prevalence, incidence, and outcomes of dementia globally with comparable data. Like all HRS data, HCAP data are publicly available at no cost to researchers.

Recent Improvements in Cognitive Functioning Among Older U.S. Adults: How Much Does Increasing Educational Attainment Explain?

OBJECTIVES

Recent interest has been generated about reports of declining incidence in cognitive impairment among more recently born cohorts. At the same time, attained education, which is related to cognition, has increased in recent cohorts of older adults. We examined cohort differences in cognitive function in a nationally representative sample of Americans aged 25 and older followed for 25 years (1986-2011) and considered the extent to which cohort differences in education account for differences.

METHOD

Data come from the Americans' Changing Lives Study (N = 3,617). Multiple cohort latent growth models model trajectories of cognition (errors on the Short Portable Mental Status Questionnaire) across four 15-year birth cohorts. Demographic factors, educational attainment, and time-varying health conditions were covariates.

RESULTS

Significant cohort differences were found in the mean number of cognitive errors (e.g., 0.26 more errors at age 65 in cohort born pre-1932 vs cohort born 1947-1961, p < .001). Although demographic and health conditions were associated with level and rate of change in cognitive dysfunction, education solely accounted for cohort differences.

DISCUSSION

Compression of cognitive morbidity is seen among the highly educated, and increasing educational opportunities may be an important strategy for decreasing the risk for cognitive impairment in later life.

Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs

OBJECTIVES

Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care.

DESIGN/SETTING/PARTICIPANTS

Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old.

MEASUREMENTS

BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity.

RESULTS

Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98-4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73-4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12-3.59; p = 0.02).

CONCLUSIONS

A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia.

Association Between Spousal Caregiver Well-Being and Care Recipient Healthcare Expenditures

OBJECTIVES

To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use.

DESIGN

Prospective cohort study.

SETTING

Health and Retirement Study.

PARTICIPANTS

Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101).

EXPOSURE

Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures.

MEASUREMENTS

Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months.

RESULTS

Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment (P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95% confidence interval (CI) = $770-3,105) and caregiver sadness (cost increase, $1,323, 95% CI = $228-2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment (P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio (OR) = 1.24, 95% CI = 1.01-1.52) and caregiver fair to poor health (OR = 1.23, 95% CI = 1.04-1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes.

CONCLUSION

Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use.

Neuroimaging overuse is more common in Medicare compared with the VA

OBJECTIVE

To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.

METHODS

Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.

RESULTS

For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions.

CONCLUSIONS

Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.

Development and validation of a brief dementia screening indicator for primary care

BACKGROUND

Detection of "any cognitive impairment" is mandated as part of the Medicare annual wellness visit, but screening all patients may result in excessive false positives.

METHODS

We developed and validated a brief Dementia Screening Indicator using data from four large, ongoing cohort studies (the Cardiovascular Health Study [CHS]; the Framingham Heart Study [FHS]; the Health and Retirement Study [HRS]; the Sacramento Area Latino Study on Aging [SALSA]) to help clinicians identify a subgroup of high-risk patients to target for cognitive screening.

RESULTS

The final Dementia Screening Indicator included age (1 point/year; ages, 65-79 years), less than 12 years of education (9 points), stroke (6 points), diabetes mellitus (3 points), body mass index less than 18.5 kg/m(2) (8 points), requiring assistance with money or medications (10 points), and depressive symptoms (6 points). Accuracy was good across the cohorts (Harrell's C statistic: CHS, 0.68; FHS, 0.77; HRS, 0.76; SALSA, 0.78).

CONCLUSIONS

The Dementia Screening Indicator is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.

Trends in depressive symptom burden among older adults in the United States from 1998 to 2008

CONTEXT

Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown.

OBJECTIVE

To examine trends in depressive symptoms among older adults in the US between 1998 and 2008.

DESIGN

Serial cross-sectional analysis of six biennial assessments.

SETTING

Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N = 16,184 in 1998).

MAIN OUTCOME MEASURE

The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none = 0, elevated = 4+, severe = 6+), adjusting for demographic and clinical characteristics.

RESULTS

Having no depressive symptoms increased over the 10-year period from 40.9 % to 47.4 % (prevalence ratio [PR]: 1.16, 95 % CI: 1.13-1.19), with significant increases in those aged ≥ 60 relative to those aged 55-59. There was a 7 % prevalence reduction of elevated symptoms from 15.5 % to 14.2 % (PR: 0.93, 95 % CI: 0.88-0.98), which was most pronounced among those aged 80-84 in whom the prevalence of elevated symptoms declined from 14.3 % to 9.6 %. Prevalence of having severe depressive symptoms increased from 5.8 % to 6.8 % (PR: 1.17, 95 % CI: 1.06-1.28); however, this increase was limited to those aged 55-59, with the probability of severe symptoms increasing from 8.7 % to 11.8 %. No significant changes in severe symptoms were observed for those aged ≥ 60.

CONCLUSIONS

Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.

Impact of cigarette smoking on utilization of nursing home services

INTRODUCTION

Few studies have examined the effects of smoking on nursing home utilization, generally using poor data on smoking status. No previous study has distinguished utilization for recent from long-term quitters.

METHODS

Using the Health and Retirement Study, we assessed nursing home utilization by never-smokers, long-term quitters (quit >3 years), recent quitters (quit ≤3 years), and current smokers. We used logistic regression to evaluate the likelihood of a nursing home admission. For those with an admission, we used negative binomial regression on the number of nursing home nights. Finally, we employed zero-inflated negative binomial regression to estimate nights for the full sample.

RESULTS

Controlling for other variables, compared with never-smokers, long-term quitters have an odds ratio (OR) for nursing home admission of 1.18 (95% CI: 1.07-1.2), current smokers 1.39 (1.23-1.57), and recent quitters 1.55 (1.29-1.87). The probability of admission rises rapidly with age and is lower for African Americans and Hispanics, more affluent respondents, respondents with a spouse present in the home, and respondents with a living child. Given admission, smoking status is not associated with length of stay (LOS). LOS is longer for older respondents and women and shorter for more affluent respondents and those with spouses present.

CONCLUSIONS

Compared with otherwise identical never-smokers, former and current smokers have a significantly increased risk of nursing home admission. That recent quitters are at greatest risk of admission is consistent with evidence that many stop smoking because they are sick, often due to smoking.

Predictors of self-report of heart failure in a population-based survey of older adults

BACKGROUND

Little research has been conducted on the predictors of self-report or patient awareness of heart failure (HF) in a population-based survey. The objective of this study was to (1) test the agreement between Medicare administrative and Health and Retirement Study (HRS) survey data and (2) determine predictors associated with self-report of HF, using a validated Medicare claims algorithm as the reference standard. We hypothesized that those who self-reported HF were more likely to have a higher number of HF-related claims.

METHODS AND RESULTS

Secondary data analysis was conducted using the 2004 wave of the HRS linked to 2002 to 2004 Medicare claims (n=5573 respondents aged ≥ 67 years). Concordance between self-report of HF in the HRS and Medicare claims was calculated. Logistic regression was performed to identify predictors associated with self-report HF. HF prevalence by self-report was 4.6%. Self-report of HF and claims agreement was 87% (κ=0.34). The presence of >1 HF inpatient claims was associated with greater odds of self-report (odds ratio [OR], 1.92; 95% CI, 1.23-3.00). Greater odds of self-reporting HF was also associated with ≥ 4 HF claims (OR, 2.74; 95% CI, 1.36-5.52). Blacks (OR, 0.28; 95% CI, 0.14-0.55) and Hispanics (OR, 0.30; 95% CI, 0.11-0.83) were less likely to self-report HF compared with whites in the final model.

CONCLUSIONS

Self-report of HF is an insensitive method for accurately identifying HF cases, especially in those with less-severe disease and who are nonwhite. There may be limited awareness of HF among older minority patients despite having clinical encounters during which HF is coded as a diagnosis.

Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study

Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients' health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION

Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

Prescription sleeping pills, insomnia, and suicidality in the National Comorbidity Survey Replication

BACKGROUND

Sedative-hypnotics have been associated with suicide attempts and completed suicides in a number of toxicologic, epidemiologic, and clinical studies. Most studies, however, inadequately address confounding by insomnia, which not only is a component of many mental health disorders that increase suicidal risk, but also is independently associated with suicidality. Moreover, the association of nonbenzodiazepine benzodiazepine receptor agonists (NBRAs) with suicidality has not been specifically studied in the US general population.

OBJECTIVE

The purpose of this study was to assess the independent contribution of prescription sedative-hypnotic use, particularly the NBRAs, to suicidal ideas, plans, and suicide attempts in the general US population, after adjusting for insomnia and other confounding variables.

METHOD

Secondary analyses of National Comorbidity Survey Replication data for 5,692 household respondents interviewed between 2001 and 2003 assessed the cross-sectional relationships between prescription sedative-hypnotic use and suicidality in the previous 12 months. Multivariate, hierarchical logistic regression analyses controlled for symptoms of insomnia, past-year mental disorders, lifetime chronic physical illnesses, and demographic variables.

RESULTS

Prescription sedative-hypnotic use in the past year was significantly associated with suicidal thoughts (adjusted odds ratio [AOR] = 2.2; P < .001), suicide plans (AOR = 1.9; P < .01), and suicide attempts (AOR = 3.4; P < .01). It was a stronger predictor than insomnia for both suicidal thoughts and suicide attempts and significantly improved the fit of these regression models (suicidal thoughts, P < .01; suicide attempts, P < .05).

CONCLUSIONS

Prescription sleeping pills, as exemplified by zolpidem and zaleplon, are associated with suicidal thoughts and suicide attempts during the past 12 months, but no evidence of causality was provided by this study. Clinical practitioners should recognize that patients taking similar types of sedative-hypnotics have a marker of increased risk for suicidality.

Incidence of dementia and cognitive impairment, not dementia in the United States

OBJECTIVE

Estimates of incident dementia, and cognitive impairment, not dementia (CIND) (or the related mild cognitive impairment) are important for public health and clinical care policy. In this paper, we report US national incidence rates for dementia and CIND.

METHODS

Participants in the Aging, Demographic, and Memory Study (ADAMS) were evaluated for cognitive impairment using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older, who were not demented at baseline, were followed longitudinally from August 2001 to December 2009. An expert consensus panel assigned a diagnosis of normal cognition, CIND, or dementia and its subtypes. Using a population-weighted sample, we estimated the incidence of dementia, Alzheimer disease (AD), vascular dementia (VaD), and CIND by age. We also estimated the incidence of progression from CIND to dementia.

RESULTS

The incidence of dementia was 33.3 (standard error [SE], 4.2) per 1,000 person-years and 22.9 (SE, 2.9) per 1,000 person-years for AD. The incidence of CIND was 60.4 (SE, 7.2) cases per 1,000 person-years. An estimated 120.3 (SE, 16.9) individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, about 3.4 million individuals aged 72 and older in the United States developed incident dementia, of whom approximately 2.3 million developed AD, and about 637,000 developed VaD. Over this same period, almost 4.8 million individuals developed incident CIND.

INTERPRETATION

The incidence of CIND is greater than the incidence of dementia, and those with CIND are at high risk of progressing to dementia, making CIND a potentially valuable target for treatments aimed at slowing cognitive decline.

"No-shows": who fails to follow up with initial behavioral health treatment?

OBJECTIVE

We sought to determine what demographic and clinical factors are associated with receipt of initial mental health treatment.

STUDY DESIGN AND METHODS

A total of 1177 patients completed structured clinical interviews (Michigan Screening for Treatment and Research Triage) when they called to authorize mental health benefits. Measures included age, sex, alcohol use, drug use, anxiety, depression, medical history, behavioral health treatment history, psychosocial stressors, functioning, and suicidality. Multivariate analyses determined the association between these variables and a behavioral health claim within 90 days of the interview.

RESULTS

Among those completing interviews, 85% attended initial mental health treatment. Factors significantly associated with increased odds of treatment initiation were good self-rated health (odds ratio [OR] = 1.70; 95% confidence interval [CI] = 1.15, 2.50), support of family or friends (OR = 1.71; 95% CI = 1.11, 2.65), previous outpatient mental health visits (OR = 1.56; 95% CI = 1.11, 2.19), and recent alcohol use (OR = 1.41; 95% CI = 1.00, 1.97). Factors associated with decreased odds of treatment initiation were recent period of total disability (OR = 0.62; 95% CI = 0.45, 0.87), any previous suicide attempt (OR = 0.56; 95% CI = 0.36, 0.87), 6 or more physician visits for medical reasons this year (OR = 0.64; 95% CI = 0.44, 0.92), and legal problems (OR = 0.31; 95% CI = 0.16, 0.61). In multivariate analyses, family support, history of medical visits, and recent alcohol use were no longer significant predictors.

CONCLUSIONS

Most individuals in this insured population who completed an initial telephone assessment had an initial behavioral health claim. However, patients with greater health or social service needs were at higher risk for not obtaining treatment, suggesting the need for greater outreach and attention by providers and insurers.

Sleep problems and suicidality in the National Comorbidity Survey Replication

OBJECTIVE

Links between sleep problems and suicidality have been frequently described in clinical samples; however, this issue has not been well-studied in the general population. Using data from a nationally representative survey, we examined the association between self-reported sleep difficulties and suicidality in the United States.

METHODS

The WHO Composite International Diagnostic Interview was used to assess sleep problems and suicidality in the National Comorbidity Survey Replication (NCS-R). Relationships between three measures of sleep (difficulty initiating sleep, maintaining sleep, early morning awaking), and suicidal thoughts, plans, and attempts were assessed in logistic regression analyses, while controlling for demographic characteristics, 12-month diagnoses of mood, anxiety and substance use disorders, and chronic health conditions.

RESULTS

In multivariate models, the presence of any of these sleep problems was significantly related to each measure of suicidality, including suicidal ideation (OR=2.1), planning (OR=2.6), and suicide attempt (OR=2.5). Early morning awakening was associated with suicidal ideation (OR=2.0), suicide planning (OR=2.1), and suicide attempt (OR=2.7). Difficulty initiating sleep was a significant predictor of suicidal ideation and planning (ORs: 1.9 for ideation; 2.2 for planning), while difficulty maintaining sleep during the night was a significant predictor of suicidal ideation and suicide attempts (ORs: 2.0 for ideation; 3.0 for attempt).

CONCLUSIONS

Among community residents, chronic sleep problems are consistently associated with greater risk for suicidality. Efforts to develop comprehensive models of suicidality should consider sleep problems as potentially independent indicators of risk.

Health-related quality of life and utilities among patients with depression in the Department of Veterans Affairs

OBJECTIVE

This study establishes veteran-specific utility measures for patients with and those without depression.

METHODS

A cross-sectional study was conducted of 87,797 Veterans Affairs (VA) patients who had completed the 12-Item Short-Form Health Survey (SF-12) portion of the VA's Large Health Survey of Veteran Enrollees administered in 1999 (58,442 veterans had an ICD-9 diagnosis of depression and 29,355 did not have such a diagnosis).

RESULTS

All demographic and clinical comparisons were statistically significant between the two groups. Compared with veterans without depression, those with depression had lower mental component scores and physical component scores, indicating worse health. Utilities, an indication of health state, were lower for veterans with depression, indicating worse health.

CONCLUSIONS

This is the first national study of utilities among veterans with and those without depression. Future research should investigate how treatment interventions may affect utilities and develop broader cost-effectiveness models of VA depression care.

Brief alcohol intervention in the emergency department: moderators of effectiveness

OBJECTIVE

Prior research supports the effectiveness of brief interventions for reducing alcohol misuse among patients in the emergency department (ED). However, limited information is available regarding the mechanisms of change, which could assist clinicians in streamlining or amplifying these interventions. This article examines moderators of outcomes among ED patients, ages 19 and older, who participated in a randomized controlled trial of a brief intervention for alcohol misuse.

METHOD

Injured patients (N= 4,476) completed a computerized survey; 575 at-risk drinkers were randomly assigned to one of four brief intervention conditions, and 85% were interviewed again at 3-month and 12-month follow-ups.

RESULTS

Regression models using the generalized estimating equations approach examined interaction effects between intervention condition (advice/no advice) and hypothesized moderator variables (stage of change, self-efficacy, acute alcohol use, attribution of injury to alcohol) on alcohol outcomes over time. Overall, participants who reported higher levels of self-efficacy had lower weekly consumption and consequences, whereas those with higher readiness to change had greater weekly consumption and consequences. Furthermore, individuals who attributed their injury to alcohol and received advice had significantly lower levels of average weekly alcohol consumption and less frequent heavy drinking from baseline to 12-month follow-up compared with those who attributed their injury to alcohol but did not receive advice.

CONCLUSIONS

This study provides novel data regarding attribution for alcohol-related injury as an important moderator of change and suggests that highlighting the alcohol/injury connection in brief, ED-based alcohol interventions can augment their effectiveness.

Mental illness, previous suicidality, and access to guns in the United States

OBJECTIVE

This study examined the association between mental disorders, prior suicidality, and access to guns and gun safety in the U.S. population.

METHODS

Using data from adult participants (N=5,692) from the National Comorbidity Survey: Replication (NCS-R), this study examined relationships between mental disorders, past suicidality, and gun access and safety practices.

RESULTS

Individuals with lifetime mental disorders (N=3,528) were as likely as those without (N=2,034) to have access to a gun (34.1% versus 36.3%; odds ratio [OR]=.9, 95% confidence interval [CI]=.8-1.1), carry a gun (4.8% versus 5.0%; OR=1.0, CI=.7-1.40), or store a gun in an unsafe manner (6.2% versus 7.3%; OR=.9, CI=.5-1.4). However, individuals with a prior suicide attempt were less likely than those without such an attempt to have access to a gun (23.8% versus 36.0%; OR=.6, CI=.5-.8).

CONCLUSIONS

Given the previously established relationship between mental health risk factors and suicide, this study highlights the need to assess for gun access among high-risk individuals.

Social Status, Risky Health Behaviors, and Diabetes in Middle-Aged and Older Adults

OBJECTIVE

This article investigates: (a) how social status influences diabetes prevalence and incidence; (b) how risky health behaviors contribute to the prediction of incident diabetes; (c) if the effects of health behaviors mediate the effects of social status on incident diabetes; and (d) if these effects differ in midlife and older age.

METHODS

We examined nationally representative data from the 1992/1993-1998 panels of the Health and Retirement Study for middle-aged and older adults using logistic regression analyses.

RESULT

The odds of prevalent diabetes were higher for people of older age, men, Black adults, and Latino adults. Higher early-life social status (e.g., parental schooling) and achieved social status (e.g., respondent schooling, economic resources) reduced the odds in both age groups. We observed similar patterns for incident diabetes in midlife but not in older age. Risky health behaviors--particularly obesity--increased the odds of incident diabetes in both age groups independent of social status. The increased odds of incident diabetes in midlife persisted for Black and Latino adults net of other social status factors.

DISCUSSION

Risky health behaviors are key predictors of incident diabetes in both age groups. Economic resources also play an important protective role in incident diabetes in midlife but not in older age.

Social status and risky health behaviors: results from the health and retirement study

OBJECTIVES

We focus on a hypothesized mechanism that may underlie the well-documented link between social status and health-behavioral health risks.

METHODS

We use longitudinal data from representative samples of 6,106 middle-aged and 3,636 older adults from the Health and Retirement Study to examine the relationships between social status-including early life social status (e.g., parental schooling), ascribed social status (e.g., sex, race-ethnicity), and achieved social status (e.g., schooling, economic resources)-and behavioral health risks (e.g., weight, smoking, drinking, physical activity) to (1) assess how early life and ascribed social statuses are linked to behavioral health risks, (2) investigate the role of achieved factors in behavioral health risks, (3) test whether achieved status explains the contributions of early life and ascribed status, and (4) examine whether the social status and health risk relationships differ at midlife and older age.

RESULTS

We find that early life, achieved, and ascribed social statuses strongly predict behavioral health risks, although the effects are stronger in midlife than they are in older age.

DISCUSSION

Ascribed social statuses (and interactions of sex and race-ethnicity), which are important predictors of behavioral health risks even net of early life and achieved social status, should be explored in future research.

Aging, cohorts, and verbal ability

OBJECTIVES

Age-related differences in cognitive abilities observed in cross-sectional samples of individuals varying in age may in part be spurious due to the effects of cohort differences in schooling and related factors. This study examined the effects of aging on cognitive function controlling for any and all differences in cohort-based social experiences of different age groups.

METHODS

We examined age-related patterns in a measure of verbal ability using 14 repeated cross-sectional surveys from the General Social Survey (GSS) over a 24-year period.

RESULTS

The raw GSS data show the expected age-related growth and decline in vocabulary knowledge, but these age differences are reduced when adjusted for cohort differences. There is evidence of small age-related patterns in vocabulary knowledge within cohorts, but the curvilinear contributions of aging to variation in verbal scores account for less than one-third of 1% of the variance in vocabulary knowledge, once cohort is controlled. Cohort differences in schooling contribute substantially to this effect.

DISCUSSION

Within-age-group variation in vocabulary knowledge is vastly more important than age differences per se, and the complexities of the relationship of verbal skills to historical differences in the experience of schooling present an interesting avenue for future research.