Racial disparities in law enforcement/court-ordered psychiatric inpatient admissions after the 2008 recession: a test of the frustration-aggression-displacement hypothesis.

BACKGROUND: Societies under duress may selectively increase the reporting of disordered persons from vulnerable communities to law enforcement. Mentally ill African American males reportedly are perceived as more threatening relative to females and other race/ethnicities. We examine whether law enforcement/court order-requested involuntary psychiatric hospitalizations increased among African American males shortly after ambient economic decline-a widely characterized population stressor. METHODS: We identified psychiatric inpatient admissions requested by law enforcement/court orders from 2006 to 2011 across four US states (Arizona, California, New York, North Carolina). Our analytic sample comprises 13.1 million psychiatric inpatient admissions across 95 counties over 72 months. We operationalized exposure to economic downturns as percent change in monthly employment in a metropolitan statistical area (MSA). We used zero inflated negative binomial and linear fixed effects regression analyses to examine psychiatric inpatient admissions requested by law enforcement/court orders following regional employment decline over a time period that includes the Great Recession of 2008. FINDINGS: Declines in monthly employment precede by one month a 6% increase in psychiatric hospitalizations requested by law enforcement/court order among African American males (p < 0.05), but not among other race/sex groups. Estimates amount to an excess of 2554 involuntary admissions among African American males statistically attributable to aggregate-level employment decline. CONCLUSIONS: Economic downturns may increase involuntary psychiatric commitments among African American males. Our findings underscore the unique vulnerability of racial/ethnic minorities during economic contractions.

Disparities in preterm birth following the July 1995 Chicago heat wave.

PURPOSE: To evaluate if changes in preterm birth (PTB, <37 weeks of gestation) incidence differed between non-Hispanic (NH) Black and NH white births following the July 1995 Chicago heat wave-among the most severe U.S. heat waves since 1950. METHODS: We used an ecologic study design. We obtained birth data from January 1990-December 1996 from the National Vital Statistics File to calculate the mean monthly PTB incidence in Chicago's Cook County, Illinois. Births between July 1995 and February 1996 were potentially exposed to the heat wave in utero. We generated time series models for NH Black and NH white births, which incorporated synthetic controls of Cook County based on unexposed counties. We ran a secondary analysis considering socioeconomic status (SES). RESULTS: From 1990-1996, the mean monthly PTB incidence among NH Black births was 18.6% compared to 7.8% among NH white births. The mean monthly PTB incidence among NH Black births from August 1995-January 1996 was 16.7% higher than expected (three additional PTBs per 100 live births per month [95% confidence interval (CI): 1, 5]). A similar increase occurred among low-SES NH Black births. No increase appeared among NH white births. CONCLUSIONS: Severe heat waves may increase racial disparities in PTB incidence.

Does the Implementation of Reference Pricing Result in Reduced Utilization? Evidence From Inpatient and Outpatient Procedures.

Reference pricing (RP) is an insurance design that can be used to incentivize patients to use low-price settings. While RP is not intended to affect overall utilization, it could unintentionally reduce utilization. We examined whether utilization was reduced when a large employer adopted RP for selected elective surgeries, including inpatient joint replacement surgery and outpatient cataract surgery, colonoscopy, and arthroscopic surgery. Data included a treatment group subject to RP implementation and a comparison group that was not. We applied autoregressive integrated moving average analysis as comparison-population interrupted time-series analysis to determine whether there were procedure reductions following RP implementation. We find no evidence of short-term decreases (within 3 months of RP implementation). However, we find very modest declines of approximately 14 (20%) fewer arthroscopic knee surgeries 6 months after RP implementation and 129 (17.2%) fewer colonoscopies 8 months after RP implementation. There were no declines in the other procedures examined.

African American Unemployment and the Disparity in Periviable Births.

Periviable infants (i.e., born before 26 complete weeks of gestation) represent fewer than .5% of births in the US but account for 40% of infant mortality and 20% of billed hospital obstetric costs. African American women contribute about 14% of live births in the US, but these include nearly a third of the country's periviable births. Consistent with theory and with periviable births among other race/ethnicity groups, males predominate among African American periviable births in stressed populations. We test the hypothesis that the disparity in periviable male births among African American and non-Hispanic white populations responds to the African American unemployment rate because that indicator not only traces, but also contributes to, the prevalence of stress in the population. We use time-series methods that control for autocorrelation including secular trends, seasonality, and the tendency to remain elevated or depressed after high or low values. The racial disparity in male periviable birth increases by 4.45% for each percentage point increase in the unemployment rate of African Americans above its expected value. We infer that unemployment-a population stressor over which our institutions exercise considerable control-affects the disparity between African American and non-Hispanic white periviable births in the US.

Understanding periviable birth: A microeconomic alternative to the dysregulation narrative.

Periviable infants (i.e., those born in the 20th through 26th weeks of gestation) suffer much morbidity and approximately half die in the first year of life. Attempts to explain and predict these births disproportionately invoke a "dysregulation" narrative. Research inspired by this narrative has not led to efficacious interventions. The clinical community has, therefore, urged novel approaches to the problem. We aim to provoke debate by offering the theory, inferred from microeconomics, that risk tolerant women carry, without cognitive involvement, high risk fetuses farther into pregnancy than do other women. These extended high-risk pregnancies historically ended in stillbirth but modern obstetric practices now convert a fraction to periviable births. We argue that this theory deserves testing because it suggests inexpensive and noninvasive screening for pregnancies that might benefit from the costly and invasive interventions clinical research will likely devise.

Recent declines in cancer incidence: related to the Great Recession?

PURPOSE: In recent years, cancer case counts in the U.S. underwent a large, rapid decline-an unexpected change given population growth for older persons at highest cancer risk. As these declines coincided with the Great Recession, we examined whether they were related to economic conditions. METHODS: Using California Cancer Registry data from California's 30 most populous counties, we analyzed trends in cancer incidence during pre-recession (1996-2007) and recession/recovery (2008-2012) periods for all cancers combined and the ten most common sites. We evaluated the recession's association with rates using a multifactorial index that measured recession impact, and modeled associations between case counts and county-level unemployment rates using Poisson regression. RESULTS: Yearly cancer incidence rate declines were greater during the recession/recovery (3.3% among males, 1.4% among females) than before (0.7 and 0.5%, respectively), particularly for prostate, lung, and colorectal cancers. Lower case counts, especially for prostate and liver cancer among males and breast cancer, melanoma, and ovarian cancer among females, were associated with higher unemployment rates, irrespective of time period, but independent of secular effects. The associations for melanoma translated up to a 3.6% decrease in cases with each 1% increase in unemployment. Incidence declines were not greater in counties with higher recession impact index. CONCLUSIONS: Although recent declines in incidence of certain cancers are not differentially impacted by economic conditions related to the Great Recession relative to pre-recession conditions, the large recent absolute declines in the case counts of some cancer may be attributable to the large declines in unemployment in the recessionary period. This may occur through decreased engagement in preventive health behaviors, particularly for clinically less urgent cancers. Continued monitoring of trends is important to detect any rises in incidence rates as deferred diagnoses come to clinical attention.

Spontaneous Pregnancy Loss in Denmark Following Economic Downturns.

An estimated 11%-20% of clinically recognized pregnancies result in spontaneous abortion. The literature finds elevated risk of spontaneous abortion among women who report adverse financial life events. This work suggests that, at the population level, national economic decline-an ambient and plausibly unexpected stressor-will precede an increase in spontaneous abortion. We tested this hypothesis using high-quality information on pregnancy and spontaneous loss for all women in Denmark. We applied time-series methods to monthly counts of clinically detected spontaneous abortions (n = 157,449) and the unemployment rate in Denmark beginning in January 1995 and ending in December 2009. Our statistical methods controlled for temporal patterns in spontaneous abortion (e.g., seasonality, trend) and changes in the population of pregnancies at risk of loss. Unexpected increases in the unemployment rate preceded by 1 month a rise in the number of spontaneous abortions (ß = 33.19 losses/month, 95% confidence interval: 8.71, 57.67). An attendant analysis that used consumption of durable household goods as an indicator of financial insecurity supported the inference from our main test. Changes over time in elective abortions and in the cohort composition of high-risk pregnancies did not account for results. It appears that in Denmark, ambient stressors as common as increasing unemployment may precede a population-level increase in spontaneous abortion.

Stroke-attributable death among older persons during the great recession.

Epidemiological evidence indicates an elevated risk for stroke among stressed persons, in general, and among individuals who have lost their job, in particular. We, therefore, tested the hypothesis that stroke accounted for a larger fraction of deaths during the Great Recession than expected from other deaths and from trends, cycles, and other forms of autocorrelation. Based on vital statistics death data from California spanning 132 months from January 2000 through December 2010, we found support for the hypothesis. These findings appear attributable to non-Hispanic white men, who experienced a 5% increase in their monthly odds of stroke-attributable death. Total mortality in this group, however, did not increase. Findings suggest that 879 deaths among older white men shifted from other causes to stroke during the 36 months following the start of the Great Recession. We infer the Great Recession may have affected social, biologic, and behavioral risk factors that altered the life histories of older white men in ways that shifted mortality risk toward stroke.

Do macroeconomic contractions induce or 'harvest' suicides? A test of competing hypotheses.

BACKGROUND: Researchers often invoke a mortality displacement or 'harvesting' mechanism to explain mortality patterns, such that those with underlying health vulnerabilities die sooner than expected in response to environmental phenomena, such as heat waves, cold spells and air pollution. It is unclear if this displacement mechanism might also explain observed increases in suicide following economic contraction, or if suicides are induced in persons otherwise unlikely to engage in self-destructive behaviour. Here, we test two competing hypotheses explaining an observed increase in suicides following unemployment-induction or displacement. METHODS: We apply time series methods to monthly suicide and unemployment data from Sweden for the years 2000-2011. Tests are conducted separately for working age (20-64 years old) men and women as well as older (aged 65 years and older) men and women. RESULTS: Displacement appeared among older men and women; an unexpected rise in unemployment predicted an increase in suicides 6 months later, followed by a significant decrease 8 months later. Induction appeared among working age men, but not among working age women; an unexpected rise in unemployment predicted an increase in suicides 4-6 months later. CONCLUSIONS: Displacement and induction both appear to have operated following unexpected labour market contractions in Sweden, though with different population segments.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Economic loss and alcohol consumption and problems during the 2008 to 2009 U.S. recession.

BACKGROUND: There is some evidence that individual-level job loss can lead to greater alcohol consumption and problems. While other forms of economic loss were common during the recent recession, these are rarely investigated in studies of macroeconomic decline. This study examined the relationship between types of economic loss in the 2008 to 2009 recession and alcohol outcomes, and whether this varied by gender and age. METHODS: Data are from the 2009 to 2010 U.S. National Alcohol Survey (N = 5,382). We used multivariable regression to estimate associations between economic loss and alcohol volume, monthly drunkenness, negative drinking consequences, and alcohol dependence in the overall sample and within gender and age groups (18 to 29, 30 to 49, 50+), controlling for demographic and alcohol history covariates. RESULTS: In the overall sample, severe economic loss (job or housing loss) was positively associated with negative drinking consequences, alcohol dependence, and (marginally) drunkenness, whereas moderate loss (loss of retirement savings, reduced work hours/wages, or trouble paying the rent/mortgage) was unassociated with alcohol outcomes. Important gender and age differences were observed. Women reporting retirement loss, reduced hours/wages, and job loss consumed 41 to 70% more alcohol than women unaffected by the recession, and men who experienced job loss and housing problems had increased risk for drunkenness, drinking consequences, and dependence. Middle-aged Americans affected by partial or complete job loss and housing problems also had greater risk of drunkenness and alcohol-related problems, and older adults who lost retirement savings drank 42% more alcohol than their peers unaffected by the recession. With the exception of negative drinking consequences, young adult alcohol outcomes were largely unrelated to recessionary loss. CONCLUSIONS: This study highlights the adverse effects of recession-induced economic losses on alcohol use and problems in demographic subgroups. As men and middle-aged Americans were at risk for multiple, adverse alcohol outcomes, these groups may warrant special alcohol screening and intervention efforts in future macroeconomic crises.

Income gains and very low-weight birth among low-income black mothers in California.

We test the hypothesis suggested in the literature that an acute income gain in the form of the earned income tax credit reduces the odds of a very low-weight birth among low-income non-Hispanic black mothers. We apply ecological time series and supplemental individual-level logistic regression methods to monthly birth data from California between 1989 and 1997. Contrary to our hypothesis, the odds of very low-weight birth increases above its expected value two months after mothers typically receive the credit. We discuss our findings in relation to the epidemiologic literature concerned with ambient events during pregnancy and recommend further investigation.

Smoking among construction workers: the nonlinear influence of the economy, cigarette prices, and antismoking sentiment.

Little research has been conducted on the influence of macroeconomic environments on smoking among blue-collar workers, a group with high smoking prevalence and that is especially vulnerable to the effects of changing economic circumstances. Using data from 52,418 construction workers in the Tobacco Use Supplement to the United States Current Population Survey, we examined the association of labor market shock, cigarette prices, and state antismoking sentiments with smoking status and average number of cigarettes smoked daily. Data analysis included the use of multiple linear and logistic regressions, which employed the sampling and replicate weights to account for sampling design. Unemployed, American-Indian, lower-educated and lower-income workers had higher smoking rates. Labor market shock had a quadratic association, which was non-significant for smoking status and significant for number of cigarettes. The association of cigarette prices with smoking status became non-significant after adjusting for state-level antismoking sentiment. State-level antismoking sentiment had significant quadratic association with smoking status among employed workers and significant quadratic association with number of cigarettes for all smokers. The study highlights how both workplace-based smoking cessation interventions and antismoking sentiments could further contribute to disparities in smoking by employment status.

Impact of capacity reductions in acute public-sector inpatient psychiatric services.

OBJECTIVE: This study tested the hypothesis that reductions in acute public-sector psychiatric inpatient capacity in a major urban area would be associated with negative impacts on patients and the community. METHODS: The impact of two discrete service changes that reduced acute inpatient capacity by 50% in a single public-sector general hospital setting was examined. Indicators of impact were obtained from existing administrative databases for a 33-month period. Indicators included measures of utilization and case mix on the acute inpatient and psychiatric emergency services, suicides among community mental health clients, and psychiatric evaluations conducted in county jails. RESULTS: Reductions in inpatient capacity were not associated with hypothesized negative impacts, such as increased demand for psychiatric emergency services, decreased access to emergency or inpatient services, or increased recidivism to inpatient care. Similarly, neither the number of suicides among community mental health clients nor the number of jail psychiatric evaluations increased after capacity reduction. CONCLUSIONS: Data from a single urban public-sector setting suggest that acute inpatient psychiatric capacity may be reduced without negative impacts on patients or the community. In this setting, collaboration between inpatient and outpatient providers to speed discharge facilitated reductions in inpatient length of stay that made it possible to serve the same number of patients with fewer resources. Other service system adjustments may be more appropriate in other settings, and alternative approaches to reducing utilization of high-cost inpatient care warrant examination.

Maternal exposure to unexpected economic contraction and birth weight for gestational age.

BACKGROUND: The macro-level economy may affect fetal health through maternal behavioral or physiologic responses. METHODS: We used a multilevel design to examine associations between exposure to state-level unexpected economic contraction during each trimester of gestation and birth weight for gestational age percentile and small for gestational age (SGA), using the National Longitudinal Survey of Youth 1979. We examined differences in observed associations by maternal educational attainment, race/ethnicity, employment status, and poverty status. RESULTS: Exposure in the first trimester was associated with a 3.7 percentile point decrease in birth weight for gestational age (95% confidence interval [CI] = -6.8 to -0.6). This association appeared stronger for women "keeping house" or with <12 years education. Exposure in the first trimester was also associated with increased odds of SGA (odds ratio = 1.5 [95% CI = 1.1 to 2.1]) and term SGA (odds ratio = 1.6 [95% CI = 1.2 to 2.3]). CONCLUSIONS: Unexpected economic contraction during early pregnancy may be associated with reduced fetal growth.

The health effects of economic decline.

Political pronouncements and policy statements include much conjecture concerning the health and behavioral effects of economic decline. We both summarize empirical research concerned with those effects and suggest questions for future research priorities. We separate the studies into groups defined by questions asked, mechanisms invoked, and outcomes studied. We conclude that although much research shows that undesirable job and financial experiences increase the risk of psychological and behavioral disorder, many other suspected associations remain poorly studied or unsupported. The intuition that mortality increases when the economy declines, for example, appears wrong. We note that the research informs public health programming by identifying risk factors, such as job loss, made more frequent by economic decline. The promise that the research would identify health costs and benefits of economic policy choices, however, remains unfulfilled and will likely remain so without stronger theory and greater methodological agreement.

The effect of community-level unemployment on preventive oral health care utilization.

OBJECTIVE: To test the hypothesis that high community-level unemployment is associated with reduced use of preventive dental care services by a dentally insured population. DATA: The study uses monthly data on population dental visits and unemployment in the Seattle and Spokane areas from 1995 to 2004. Utilization data come from Washington Dental Services. Unemployment data were obtained from the Bureau of Labor Statistics and Washington's Employment Security Department. STUDY DESIGN: The study uses a Box-Jenkins Autoregressive Integrated Moving Average (ARIMA) method to measure the association between the variables over time. The approach controls for the effects of autocorrelation, seasonality, and confounding variables. FINDINGS: In the Seattle area, an unexpected 10,000 unit increase in the number of unemployed individuals is associated with a 1.24 percent decrease in preventive visits during the month ( p=.0043). In the Spokane area, a similar increase in unemployment is associated with a 5.95 percent decrease in preventive visits ( p=.0326). The findings persist when the independent variable is the number of initial unemployment insurance claims. CONCLUSIONS: The analysis suggests that utilization of preventive dental care declines during periods of high community-level unemployment. Community-level unemployment may impede or distract populations from utilizing preventive dental services. The study's findings have implications for insurers, dentists, policy makers, and researchers.

Rates of unemployment and incidence of police-initiated examinations for involuntary hospitalization in Florida.

OBJECTIVE: This study tested the hypothesis that contraction of regional economies affects the incidence of involuntary admissions to psychiatric emergency services by reducing community tolerance for persons perceived as threatening to others. METHODS: This hypothesis was tested with time-series analyses of the relationship between initial claims for unemployment in Florida between July 4, 1999, and June 28, 2003, and the weekly number of men and women presented by police to be examined for involuntary psychiatric hospitalization because of danger to others. The analyses controlled for admissions presented by mental health professionals because of danger to others and for admissions presented by police because of neglect or disability. RESULTS: When the analyses controlled for autocorrelation and other covariates, claims for unemployment insurance were significantly associated with the number of men presented by police for danger to others. During the study period, police presented 5,897 men for examination because of danger to others. Increased unemployment claims were associated with approximately 309 more men being presented for examination than expected from prior presentation rates and from the number presented by mental health professionals for danger to others and by police for neglect or disability. No such association was found for women. CONCLUSIONS: Consistent with theory, this study found that presentations for involuntary admission to psychiatric services increased after contractions in the labor market. Combining the methods of this study with econometric forecasting may allow providers to anticipate better the need for psychiatric services.