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Mental Illness and Substance Use Disorders Among Veteran Clinic Users with Spinal Cord Injury. Ranjana Banerjea, PhD Usha Sambamoorthi, PhD Leonard M Pogach, MD, MBA Frances Weaver, PhD Thomas Findley, MD Veterans Health Administration, East Orange. Background. - PowerPoint PPT Presentation
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Mental Illness and Substance Use Mental Illness and Substance Use Disorders Among Veteran Clinic Users Disorders Among Veteran Clinic Users
with Spinal Cord Injurywith Spinal Cord Injury
Ranjana Banerjea, PhDRanjana Banerjea, PhDUsha Sambamoorthi, PhDUsha Sambamoorthi, PhD
Leonard M Pogach, MD, MBALeonard M Pogach, MD, MBAFrances Weaver, PhD Frances Weaver, PhD Thomas Findley, MDThomas Findley, MD
Veterans Health Administration, East OrangeVeterans Health Administration, East Orange
BackgroundBackground
State of Research: State of Research: Conflicting ViewsConflicting Views
Spinal Cord Injury (SCI) patients Spinal Cord Injury (SCI) patients are are at high riskat high risk for mental illnesses (MI) for mental illnesses (MI)– depression, anxiety, post-traumatic depression, anxiety, post-traumatic
stress disorder (PTSD)stress disorder (PTSD)– clinical-level stressclinical-level stress– negative consequences of physical and negative consequences of physical and
social functioning social functioning
SCI patients SCI patients do notdo not have elevated have elevated rates of depressionrates of depression
Resolving the Resolving the Conflicting ViewsConflicting Views
Early/acute stages may show Early/acute stages may show increase in depressive symptoms increase in depressive symptoms
Positive effect of time on the Positive effect of time on the attenuation of depressive attenuation of depressive symptoms symptoms
SCI Patients have SCI Patients have highhigh rates rates of Substance Use Disordersof Substance Use Disorders
SCI also SCI also have have high rates ofhigh rates of SUDs SUDs– In community-based studiesIn community-based studies
52% overall 52% overall
21% alcohol abuse 21% alcohol abuse
16% marijuana use 16% marijuana use
– Other studies Other studies
Prior heavy drinkers tend to drink daily Prior heavy drinkers tend to drink daily
21% drugs within the past 6-12 months21% drugs within the past 6-12 months
SUD rates may have been high SUD rates may have been high even before injuryeven before injury
Pre-injury usePre-injury use– alcohol and substance use alcohol and substance use highly highly
correlatedcorrelated with the events that cause with the events that cause the SCIthe SCI
Evidence needs to be piecedEvidence needs to be pieced
No large scale studiesNo large scale studiesConvenient samples usedConvenient samples usedDiffering time periods (immediately Differing time periods (immediately after injury versus many years later)after injury versus many years later)Focus on PTSD /DepressionFocus on PTSD /DepressionNo focus on all types of substances No focus on all types of substances Subgroup differences not knownSubgroup differences not known
ObjectivesObjectives
Document Document prevalenceprevalence of mental illness of mental illness (MI) and substance use disorders (MI) and substance use disorders (SUD) among veterans with SCI (SUD) among veterans with SCI
Estimate Estimate typestypes of MI and SUD in SCI of MI and SUD in SCI veteransveterans
Examine the Examine the predictorspredictors of MI and SUD of MI and SUD in SCI veteransin SCI veterans
DesignDesignVeterans with SCI diagnoses in Veterans Veterans with SCI diagnoses in Veterans Health Administration’s (VHA) based on Health Administration’s (VHA) based on the Spinal Cord Dysfunction-Registry the Spinal Cord Dysfunction-Registry (SCD-R)(SCD-R)
Veterans who had outpatient face-to-face Veterans who had outpatient face-to-face utilization or hospitalization either in the utilization or hospitalization either in the VHA, the Medicare fee-for-service or both VHA, the Medicare fee-for-service or both systemssystems
Longitudinal cohort from fiscal years (FY) Longitudinal cohort from fiscal years (FY) 1999 to 2002 1999 to 2002
Research DesignResearch Design
SCD-RN=36,987
VHA Admin
MedicareFFS
2. Merged VHA with Medicare (FFS) utilization
1. Merged SCD-R with VHA data
(current use: FY1999-2002)
Merged data
2
1
Study PopulationStudy Population(N = 8,338)(N = 8,338)
InclusionsValid Onset date
Onset before study period (FY 1999)Alive during entire study (FY 1999-2002)
Utilization in VA or Medicare or both
Final datasetN=8,338
Missing dataMissing data
In the registry : ICD-9-CM diagnostic In the registry : ICD-9-CM diagnostic codes from VHA and Medicare were usedcodes from VHA and Medicare were used
In demographics: missing in VHA was In demographics: missing in VHA was replaced by Medicare. When missing from replaced by Medicare. When missing from all sources it was used as a separate all sources it was used as a separate category in regressions.category in regressions.
MeasuresMeasures
Dependent VariablesDependent Variables(FY 2000-2001)(FY 2000-2001)
Mental Illness and Substance Use Disorder (MI/SUD)(MI/SUD) Categories (ICD-9-CM codes)MI:MI: schizophrenia, depressive disorders, bipolar and other psychoses, anxiety and PTSD SUD:SUD: alcohol, drug, and tobacco use
– Drug and alcohol: we further distinguished between abuse, dependence and other.
We combined dependence and abuse diagnoses in alcohol and drug
– Due to high co-occurrence of dependence and abuse and under-coding of only dependence code (drug abuse – 1% and alcohol abuse – 2%)
Independent Variables
Statistical ProceduresStatistical Procedures
Chi-square tests Chi-square tests – bivariate associations between MI/SUD bivariate associations between MI/SUD
categories and the independent variables. categories and the independent variables.
Multinomial logistic regressionMultinomial logistic regression– the predictors of the MI/SUD categories. the predictors of the MI/SUD categories. – adjusted odds ratios at 95% CI. adjusted odds ratios at 95% CI. – p-value < 0.01p-value < 0.01
ResultsResults
Description of Study population (%)Description of Study population (%)(N = 8,338)(N = 8,338)
9.8%
2.6%5.3% 6.3%
3.2%
26.7%
Type of MI
Anxiety Disorders Bipolar Disorder DepressionPsychoses PTSD Schizophrenia
Depression was very common
ANY MI = 34%
Tobacco use was very commonTobacco use was very common
18.9%
9.0%
8.0%
Type of MITobacco Alcohol Drug
Any SUD = 26.3%
Mental illness by Mental illness by substances usedsubstances used
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0
Anxiety Disorders
Bipolar Disorder
Depression
Psychoses
PTSD
Schizophrenia
Percentage
Tobacco
Drug
Alcohol
MI/SUD CategoriesMI/SUD Categories
MI/SUD categoriesMI/SUD categories were constructed were constructed broadly by combining MI and SUD and broadly by combining MI and SUD and included 4 groups: included 4 groups:
1.1. No MI/SUDNo MI/SUD
2.2. MI onlyMI only
3.3. SUD onlySUD only
4.4. MI/SUD bothMI/SUD both
20%
14%
54%
12%
Over 2 years, 46% had either MI and/or SUD
MI ONLY
SUD ONLY
BOTH
NONE
Rates of mental illness and/or SUD varied by co-morbid conditions
32.3
48.140.3
46.5 47.9 46.0
25.2
28.031.1
25.7 23.8 23.0
15.5
9.410.3 12.0 11.7 13.0
27.014.5 18.3 15.9 16.7 18.0
0%
20%
40%
60%
80%
100%
COPD DM HeartDisease
HTN UTI SkinUlcer
None MI only SUD ony MI/SUD
Multinomial Logistic Regression Comorbidities Comorbidities
MI Only * SUD Only *MI/SUD *
Diabetes
Skin ulcer
Hypertension
COPD
Heart Dis.
UTI
* P <.001
Depression
Adjusted Odds Ratios Multinomial Logistic RegressionAfrican Americans and Latinos
Mi only, 0.71
Mi only, 1.09
SUD only, 0.96SUD only, 0.56
MI/SUD, 0.95
MI/SUD, 0.79
0.30
0.50
0.70
0.90
1.10
1.30
1.50
1 2
Adj
uste
d O
dds
OR
atio
ss
African AmericanLatinoAfrican American Latino
Adjusted Odds RatiosAdjusted Odds RatiosMultinomial Logistic Regression Multinomial Logistic Regression
Duration of SCIDuration of SCI
MI only, 0.51
MI only, 0.69MI only, 0.61
SUD only, 0.78 SUD only, 0.77 SUD only, 0.57
MI/SUD, 0.32
MI/SUD, 0.52MI/SUD, 0.55
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1 2 3
Od
d R
atio
s
10-19 yrs 30 plus yrs20-29 yrs
ConclusionsConclusions
Among veterans with SCI, the prevalence of MI Among veterans with SCI, the prevalence of MI or SUD or both was high (47%) or SUD or both was high (47%) – higher than the 15% in earlier study (Radnitz et al., higher than the 15% in earlier study (Radnitz et al.,
1996). 1996).
Depressive disorders (27%) were comparable to Depressive disorders (27%) were comparable to a recent study of SCI veterans over a three year a recent study of SCI veterans over a three year period (Smith et al., 2007) period (Smith et al., 2007) Our findings revealed that depressive disorders Our findings revealed that depressive disorders were the most common diagnoses. All other were the most common diagnoses. All other diagnoses were present in less than 10% of the diagnoses were present in less than 10% of the population. population.
ConclusionsConclusionsThe association of MI or SUD and physical The association of MI or SUD and physical illnesses in SCI patients was dependent illnesses in SCI patients was dependent on the type of illnesson the type of illness– diabetes were more likely to have depressiondiabetes were more likely to have depression– Skin Ulcer, COPD and hypertension were Skin Ulcer, COPD and hypertension were
strongly associated with MI or SUD in all strongly associated with MI or SUD in all combinationscombinations
– UTI and heart disease were significantly UTI and heart disease were significantly associated with either MI or both MI/SUD. associated with either MI or both MI/SUD.
ConclusionsConclusions
African Americans were less likely to have MI African Americans were less likely to have MI onlyonly
Duration SCI was protective – progressive Duration SCI was protective – progressive decrease in MI and/or SUDdecrease in MI and/or SUD
Paraplegia patients have more SUDParaplegia patients have more SUD
Chronic illness – patterns of MI/SUD were Chronic illness – patterns of MI/SUD were different different
ImplicationsImplicationsNewer SCI patients have depression after the Newer SCI patients have depression after the rehabilitation phase, but that does abate over time rehabilitation phase, but that does abate over time (Richards, 1986; Kennedy & Rogers, 2000). (Richards, 1986; Kennedy & Rogers, 2000). Regular screening of depression among SCI for early Regular screening of depression among SCI for early detection and treatment during hospitalization, rehab and detection and treatment during hospitalization, rehab and outpatient therapies outpatient therapies Targeted efforts for tobacco use cessation and Targeted efforts for tobacco use cessation and counselingcounselingHigh rates of psychiatric conditions and SUDs, High rates of psychiatric conditions and SUDs, specifically among those with a chronic physical illness specifically among those with a chronic physical illness suggestsuggest– significantly high expenditures and significantly high expenditures and – challenges to chronic illness management in the SCI populationchallenges to chronic illness management in the SCI population
LimitationsLimitations
Temporal process of MI can not be testedTemporal process of MI can not be tested– Pre-injury SUD is very highPre-injury SUD is very high
High attrition of study population due to High attrition of study population due to missing on-set datemissing on-set date
MI and SUD may be under-coded MI and SUD may be under-coded – Ours may be considered as a lower-bound Ours may be considered as a lower-bound
estimateestimate
StrengthsStrengthsOur study highlights the complexity of Our study highlights the complexity of illness burden in the SCI veteran illness burden in the SCI veteran population population – Subgroup differences in MI/SUD foundSubgroup differences in MI/SUD foundLarge scale study Large scale study
Differing time periods (immediately after Differing time periods (immediately after injury versus many years later)injury versus many years later)Focus on the gamut of MI and SUDFocus on the gamut of MI and SUD– includes schizophrenia to anxiety disordersincludes schizophrenia to anxiety disorders– includes smokingincludes smoking
Special Thanks toSpecial Thanks to
Patricia Findley, DrPH, MSWPatricia Findley, DrPH, MSW
Bridget Smith, PhDBridget Smith, PhD
Thank youThank youon behalf of a special populationon behalf of a special population