Financial hardship among individuals with serious mental illness.

This study explored financial hardship, defined as difficulty in obtaining food, shelter, or medicine in the past 12 months and its personal and clinical correlates in individuals with serious mental illness (SMI) in a sample of 271 adults with SMI newly admitted to two inner city community mental health centers. The study found that 59 percent (n = 161) reported experiencing financial hardship in the past 12 months. Patients with financial hardship were more likely to be female, to experience self-stigma, to experience medical care delays, and to use emergency services. Patients who experienced financial hardship typically had more severe psychiatric symptoms, including depressive symptoms, emotional lability, and interpersonal problems. Financial hardship persisted in nearly half of those with hardship interviewed a year later. The findings highlight the role of multiple social and economic challenges that the SMI patients face in recovery from serious mental illness and the importance of awareness of such challenges by providers treating this population. Though mental health treatment may help alleviate the psychiatric symptoms it alone is not sufficient in addressing persistent hardship. These findings highlight the need for multidisciplinary interventions in order to better serve this vulnerable population.

Recent advances in the prevention of mental disorders.

PURPOSE: Prevention of mental disorders is a rapidly growing area of research with substantial potential benefits for population health. This paper reviews the evidence base for prevention of depression, anxiety, and schizophrenia. METHODS: We synthesized evidence from recent systematic reviews and meta-analyses published between 2013 and 2018 on prevention of depression, anxiety, and first-episode psychosis. We included reviews of randomized controlled trials testing psychological, psychosocial, and pharmacological preventive interventions. RESULTS: There is good evidence that depression and anxiety can be prevented, although effect sizes are generally small. Indicated prevention of first-episode psychosis appears promising. Economic evaluations provide support for prevention of depression, anxiety, and first-episode psychosis, but more studies evaluating costs and benefits are needed to strengthen the knowledge base, particularly regarding long-term outcomes, which include chronicity of the prevented disorder, as well as later occurence of important comorbid mental and physical health problems. Promising areas for further development include internet- or computer-based prevention strategies, mindfulness-based interventions, and integration of prevention programs within occupational settings. CONCLUSIONS: A number of interventions to prevent mental disorders are efficacious. While intervention effect sizes are generally small for prevention of depression and anxiety, they may nonetheless be of significant population benefit. Using the growing evidence base to inform policy and dissemination of evidence-based prevention programs is critical for moving prevention science into real-world settings.

Costs of substance use disorders from claims data for Medicare recipients from a population-based sample.

Medicare spending is projected to increase over the next decade, including for substance use disorders (SUD). Our objective was to determine whether SUDs are associated with higher six-year Medicare costs (1999-2004) among participants in the Baltimore Epidemiologic Catchment Area (ECA) Study. Medicare claims data for the years 1999-2004 from the Centers for Medicare and Medicaid Services were linked to four waves of data from the Baltimore ECA cohort collected between 1981 and 2005 (n=566). A generalized linear model with a log link and gamma distribution was used to examine direct Medicare costs associated with SUD status. Medicare recipients with no history of SUD had mean six-year costs of $42,576. Those with a history of SUD based on both Baltimore ECA and Medicare data, or based on Medicare claims data alone, had significantly higher costs ($98,754 and $64,876, respectively). A history of SUD based solely on Baltimore ECA data alone had lower average costs ($25,491). Findings indicate that Medicare costs differ by source of SUD diagnosis when comparing treatment versus survey data. This may have future implications for projecting Medicare costs among SUD individuals as healthcare coverage expands under the Affordable Care Act.

Analysis of the Association of Clubhouse Membership with Overall Costs of Care for Mental Health Treatment.

We examined whether frequency of attendance at the B'More Clubhouse was associated with lower mental health care costs in the Medicaid database, and whether members in the B'More Clubhouse (n = 30) would have lower mental health care costs compared with a set of matched controls from the same claims database (n = 150). Participants who attended the Clubhouse 3 days or more per week had mean 1-year mental health care costs of US $5697, compared to $14,765 for those who attended less often. B'More Clubhouse members had significantly lower annual total mental health care costs than the matched comparison group ($10,391 vs. $15,511; p < 0.0001). Membership in the B'More Clubhouse is associated with a substantial beneficial influence on health care costs.

COSTS OF DEPRESSION FROM CLAIMS DATA FOR MEDICARE RECIPIENTS IN A POPULATION-BASED SAMPLE.

BACKGROUND: Many persons with depressive disorder are not treated and associated costs are not recorded. AIMS OF THE STUDY: To determine whether major depressive disorder (MDD) is associated with higher medical cost among Medicare recipients. METHODS: Four waves of the Baltimore-Epidemiologic Catchment Area (Baltimore ECA) Study conducted between 1981 and 2004 were linked to Medicare claims data for the years 1999 to 2004 from the Centers for Medicare and Medicaid Services (CMS). Generalized linear models specified with a gamma distribution and log link function were used to examine direct medical care costs associated with MDD. RESULTS: Medicare recipients with no history of MDD in either the ECA or CMS data had mean six-year medical costs of US $40,670, compared to $87,445 for Medicare recipients with MDD as recorded in CMS data and $43,583 for those with MDD as recorded in Baltimore-ECA data. Multivariable regressions found that compared to Medicare recipients with no history of depression, those with depression identified in the CMS data had significantly higher medical costs; about 1.87 times (95% confidence interval (CI) 1.32 to 2.67) higher. Medicare recipients with a history of depression identified in the ECA data were no more likely to have higher costs than were Medicare recipients with no history of depression (relative ratio 1.33, 95% CI 0.87 to 2.02). DISCUSSION: Medicare recipients with a history of depression identified in claims data had significantly higher medical costs than recipients with no history of depression. However, no significant differences were found between Medicare recipients with depression in the community-based Baltimore ECA data and those with no history of depression. The results show that the source of diagnosis, in treatment versus survey data, produces differences in results as regards costs. LIMITATIONS: This study involved only Medicare recipients with claims data over the six years 1999 to 2004. Many of the ECA respondents were too young to qualify for Medicare. IMPLICATIONS FOR HEALTH POLICY: Depressive disorder involves substantial medical care costs. The findings provide information on the economic burden of depression, an important but often omitted dimension and perspective of the burden of mental illnesses.

Previous anxiety and depression as risk factors for early labour force exit.

BACKGROUND: Individuals with a history of mental illness have lower earnings than individuals without. A possible reason is that those with prior anxiety or depression may be more likely to exit the labour force prior to retirement age, but evidence has been mixed and limited. Our objective was to compare risk of early labour force exit between employed adults with a history of depression or anxiety versus those without, separately for men and women. METHODS: We used data from the Baltimore Epidemiological Catchment Area Follow-up Cohort, which collected baseline data in 1981 and follow-up data 1993-1996 and 2004-2005. Cox proportional hazards models estimated the relative risk of labour force exit comparing those with versus without prior history of anxiety or depressive disorders. RESULTS: Women with prior anxiety or depression are at 37% increased risk of dropping out of the labour force as compared to women without, controlling for age, socioeconomic status, race and marital status (HR: 1.37, 95% CI 1.04 to 1.79). Men with prior anxiety or depression are 18% more likely to subsequently drop out of the labour force as compared to men without, controlling for the above confounders as well as veteran status, but this association is not statistically significant (HR: 1.18, 95% CI 0.72 to 1.27). CONCLUSIONS: Prior anxiety or depression increases risk of early labour force exit for women. These findings may help explain previously reported lower earnings among female individuals with a history of mental illness and highlight the importance of considering anxiety and depressive disorders in policies supporting labour force participation.

Interrater reliability of the modified Monitoring of Side Effects Scale for assessment of adverse effects of psychiatric medication in clinical and research settings.

The assessment of adverse effects of psychiatric medications is important in clinical and research settings because they are often associated with medication discontinuation, symptom exacerbation, and reduced quality of life. Currently available assessment tools are either limited with regard to the number and variety of included adverse effects or are not practical for use in most clinical or research settings owing to specialized rater training required and administration length. This report describes a modification of the Monitoring of Side Effects Scale (MOSES), an established adverse effect rating scale, by adding severity anchors to improve its reliability and ease of use. Interrater reliability was good for 7 of the 8 bodily adverse effects assessed, with intraclass correlation coefficients ranging from 0.76 to 0.91 in a sample of patients with severe mental illness. This modified version of the Monitoring of Side Effects Scale holds promise as a useful tool for assessing medication adverse effects in clinical and research settings.

A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders.

IMPORTANCE: Understanding the epidemiologic profile of the life course of mental disorders is fundamental for research and planning for health care. Although previous studies have used population surveys, informative and complementary estimates can be derived from population-based registers. OBJECTIVE: To derive comprehensive and precise estimates of the incidence rate of and lifetime risk for any mental disorder and a range of specific mental disorders. DESIGN, SETTING, AND PARTICIPANTS: We conducted a follow-up study of all Danish residents (5.6 million persons), to whom all treatment is provided by the government health care system without charge to the patient, from January 1, 2000, through December 31, 2012 (total follow-up, 59.5 million person-years). During the study period, 320,543 persons received first lifetime treatment in a psychiatric setting for any mental disorder; 489,006 persons were censored owing to death; and 69,987 persons were censored owing to emigration. Specific categories of mental disorders investigated included organic mental disorders, substance abuse disorders, schizophrenia, mood disorders, anxiety, eating disorders, personality disorders, mental retardation, pervasive developmental disorders, and behavioral and emotional disorders. EXPOSURES: Age and sex. MAIN OUTCOMES AND MEASURES: Sex- and age-specific incidence rates and cumulative incidences and sex-specific lifetime risks. RESULTS: During the course of life, 37.66% of females (95% CI, 37.52%-37.80%) and 32.05% of males (31.91%-32.19%) received their first treatment in a psychiatric setting for any mental disorder. The occurrence of mental disorders varied markedly between diagnostic categories and by sex and age. The sex- and age-specific incidence rates for many mental disorders had a single peak incidence rate during the second and third decades of life. Some disorders had a second peak in the sex- and age-specific incidence rate later in life. CONCLUSIONS AND RELEVANCE: This nationwide study provides a first comprehensive assessment of the lifetime risks for treated mental disorders. Approximately one-third of the Danish population received treatment for mental disorders. The distinct signatures of the different mental disorders with respect to sex and age have important implications for service planning and etiologic research.

Reasons for not seeking general medical care among individuals with serious mental illness.

OBJECTIVE: The study compared delays in seeking general medical care among adults with serious mental illness and a general population sample. Associations of delays with health status and use of emergency department services among individuals with serious mental illness were also assessed. METHODS: Data for 271 persons with serious mental illness (clinic sample) and 40,016 participants in the National Health Interview Survey (NHIS sample) were compared. RESULTS: Fifty-three percent of the clinic sample and 13% of the NHIS sample reported delays, most because of difficulties accessing services. In the clinic sample, delays were associated with receipt of routine care at a public clinic, rather than a physician's office; more severe depressive symptoms; and functional difficulties. Delays were also associated with poorer health status and use of emergency department services. CONCLUSIONS: Integration of services as envisioned in the Affordable Care Act and targeted case management may reduce delays among individuals with serious mental illness.

Economic grand rounds: Income inequality and depression prevalence across the United States: an ecological study.

Research has shown a relationship between income inequality and poor health. This column reports findings from a state-level study of the relationship between income inequality and the prevalence of depression. Estimates of depression prevalence by state, obtained from the Behavioral Risk Factor Surveillance System, were linked with Gini coefficients for U.S. household income, obtained from the Census Bureau. The current prevalence of depression was significantly associated with income inequality--the more unequal, the higher the depression prevalence. The association persisted after adjustment for income per capita, percentage of the population with a college degree, and percentage over age 65 years.

Reconsidering the role of social disadvantage in physical and mental health: stressful life events, health behaviors, race, and depression.

Prevalence of depression is associated inversely with some indicators of socioeconomic position, and the stress of social disadvantage is hypothesized to mediate this relation. Relative to whites, blacks have a higher burden of most physical health conditions but, unexpectedly, a lower burden of depression. This study evaluated an etiologic model that integrates mental and physical health to account for this counterintuitive patterning. The Baltimore Epidemiologic Catchment Area Study (Maryland, 1993-2004) was used to evaluate the interaction between stress and poor health behaviors (smoking, alcohol use, poor diet, and obesity) and risk of depression 12 years later for 341 blacks and 601 whites. At baseline, blacks engaged in more poor health behaviors and had a lower prevalence of depression compared with whites (5.9% vs. 9.2%). The interaction between health behaviors and stress was nonsignificant for whites (odds ratio (OR = 1.04, 95% confidence interval: 0.98, 1.11); for blacks, the interaction term was significant and negative (ß: -0.18, P < 0.014). For blacks, the association between median stress and depression was stronger for those who engaged in zero (OR = 1.34) relative to 1 (OR = 1.12) and ≥2 (OR = 0.94) poor health behaviors. Findings are consistent with the proposed model of mental and physical health disparities.

Health insurance coverage among persons with schizophrenia in the United States.

OBJECTIVE: This study estimated the rates of health insurance coverage in the U.S. civilian noninstitutionalized population with schizophrenia and assessed whether basic access to health care varied across health insurance categories. METHODS: Data from the Medical Expenditures Panel Survey collected between 2002 and 2006 were used. RESULTS: The sample contained 328 records representing 493,006 noninstitutionalized civilian persons with schizophrenia. Eighty-seven percent had Medicaid or Medicare, 8% received care through the Veterans Health Administration, and 15% had private insurance for at least one day during the year. About 7% were uninsured all of the year. The uninsured tended to be male (92%), nonwhite (54%), and unmarried (97%), and 30% of the uninsured had not had a medical checkup in more than five years. CONCLUSIONS: Almost all U.S. adults with schizophrenia were found to receive government health insurance, yet a measurable minority remained uninsured. These national estimates highlight opportunities for improving health service delivery for this vulnerable population.

Mediating effect of mental disorders in the pathway between life events and mental health services use: results from the Baltimore Epidemiologic Catchment Area study.

This study assessed the role of some common mental health conditions as mediators in the pathway between suffering life events and using mental health services. The participants were from the Baltimore Epidemiologic Catchment Area cohort, interviewed in 1993 to 1996 and 2004 to 2005. Longitudinal data analysis was used to identify models with significant mediation. Only alcohol abuse/dependence disorder was a significant mediator in the pathway between suffering a life-threatening illness and using mental health services in a general medical setup. Female gender, being more than 65 years old, prior use of services and availability of health insurance were some of the factors that significantly predicted service use in that model. Some of other factors like social networks and social support, attitudes towards services, and stigma, may play a role in determining service use. Future research should investigate the role of such factors as mediators for mental health service use.

The burden of mental disorders.

In the last decade, there has been an increase in interest in the burden of chronic and disabling health conditions that are not necessarily fatal, such as the mental disorders. This review systematically summarizes data on the burden associated with 11 major mental disorders of adults. The measures of burden include estimates of prevalence, mortality associated with the disorders, disabilities and impairments related to the disorders, and costs. This review expands the range of mental disorders considered in a report on the global burden of disease, updates the literature, presents information on the range and depth of sources of information on burden, and adds estimates of costs. The purpose is to provide an accessible guide to the burden of mental disorders, especially for researchers and policy makers who may not be familiar with this subfield of epidemiology.

Prevalence and correlates of hoarding behavior in a community-based sample.

Little is known about the prevalence and correlates of hoarding behavior in the community. We estimated the prevalence and evaluated correlates of hoarding in 742 participants in the Hopkins Epidemiology of Personality Disorder Study. The prevalence of hoarding was nearly 4% (5.3%, weighted) and was greater in older than younger age groups, greater in men than women, and inversely related to household income. Hoarding was associated with alcohol dependence; paranoid, schizotypal, avoidant, and obsessive-compulsive personality disorder traits; insecurity from home break-ins and excessive physical discipline before 16 years of age; and parental psychopathology. These findings suggest that hoarding may be relatively prevalent and that alcohol dependence, personality disorder traits, and specific childhood adversities are associated with hoarding in the community.

Participant characteristics that influence consent for genetic research in a population-based survey: the Baltimore epidemiologic catchment area follow-up.

BACKGROUND: The purpose of this study is to investigate the sociodemographic and health characteristics associated with the willingness to donate a DNA sample, and consent to testing and long-term storage of that sample, among participants in a longitudinal community-based survey. SAMPLE: Eighty-three percent of the 1,071 participants interviewed in 2004/5 agreed to donate a biological specimen (blood or buccal). RESULTS: Age was consistently inversely associated with the willingness to allow genetic testing (OR 0.97; p < 0.05), but was unrelated to the willingness to donate or allow storage. There was no association between race and the consent to donate a specimen, but Blacks were less likely to consent to DNA storage for future research as compared with members of other racial groups (OR 0.50; p < 0.01). Four conditions were listed on the consent form as relevant to the genes targeted for assay. Participants with a family history of 1 or more of these conditions were more likely to donate than those without (OR 1.68; p < 0.01). Participants with a personal history of 1 of the 4 conditions listed were not more or less likely to donate, allow testing or allow storage than respondents without such a history. CONCLUSIONS: Sociodemographic characteristics were unrelated to the willingness to donate a biological sample. Age, but not race, sex or education, was related to consent to genetic testing. Race, but not age, sex or education, was related to consent to storage. A family history of health conditions listed as relevant to the assays being requested was related to the willingness to donate. Factors that affect the willingness to donate a biological sample in an epidemiologic study are not the same as those associated with the willingness to allow genetic testing or storage of that sample for unspecified future research.

Disparities in psychological distress across education and sex: a longitudinal analysis of their persistence within a cohort over 19 years.

PURPOSE: Disparities in psychological distress across socioeconomic status and sex persist throughout adulthood as cohorts age. In this study, we investigate the extent to which this persistence represents either (i) a single set of individuals who at the start of adulthood show distress that is chronic and long lasting or (ii) different sets of individuals that have a staggered onset of short-term distress throughout adulthood. METHODS: We use path analysis on data from the National Child Development Study, a longitudinal cohort study that assessed psychological distress at ages 23, 33, and 42 years. RESULTS: About 80% of distress disparities at age 42 result from chronic distress that was present in a single set of individuals at least 19 years earlier at the beginning of adulthood. CONCLUSIONS: These results support a targeted approach to the reduction of distress disparities that focuses on young adults with high levels of distress and seeks to improve their long-term mental health.

Mental health disparities across education and sex: a prospective analysis examining how they persist over the life course.

OBJECTIVES: Higher levels of psychopathology among people with lower socioeconomic status and among women persist as cohorts age. In this analysis, we examine whether the persistence of these disparities as a cohort ages results from (a) a single set of people within a disadvantaged group who have chronic psychopathology or (b) continually changing sets of people within a disadvantaged group who have psychopathology of short duration. METHODS: Data for this analysis come from the Epidemiologic Catchment Area Study, which includes two psychological assessments (depressive syndrome and psychological distress) in a population sample of adults in Baltimore, Maryland, collected 13 years apart. RESULTS AND DISCUSSION: Results indicate that the persistence of disparities across education resulted primarily from one single set of respondents with chronic psychopathology over the 13 years of the survey, while the persistence of disparities across sex involved new sets of women as the cohort aged. We discuss implications of these results for theory and policy.