California Child and Youth Injury Hot Spots Project - FHOP

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					Trends in mental health and
 related hospitalizations in
California’s reproductive age
   population, 1991-2005
            APHA November 2008
                  San Diego, CA
                                  1
         Presenter Disclosures
The following personal financial relationships with commercial
interests relevant to this presentation existed during the past
                 12 months: None to disclose.

                Gerry Oliva, MD MPH
               Linda Remy, MSW PhD
                    Ted Clay, MS

             Family Health Outcomes Project
       Department of Family and Community Medicine
          University of California, San Francisco

                                                             2
     Impetus for this study
In the National Co-morbidity Survey (Kessler
2005) 32% of adults reported mental illness
(MI) in the last year and 57% in their lifetime
The National Institute for Mental Health:
reports that 67% of women and 76% of men
with MI are parents (Nicholson, SAMHSA
2004)
Women with MI history are at increased risk of
MI episodes during pregnancy and post-
partum depression (Rich-Edwards 2006)
                                                  3
       Impetus for this study
Pregnant women with MI at increased risk of
having infants with birth defects, pre-term birth
and low birthweight (Carmichael 2007, Field 2008)
Older children of depressed mothers suffer
impaired social, emotional, intellectual and
language development (Onunaku 2005)
Children of MI parents are at increased risk for
developing major depression, anxiety disorders,
and substance dependence. (Biederman 2001)

                                                   4
     Impetus for this study
70-80% of MI mothers lose children to foster
care (Joseph 1999)
Less half of those needing MI services are able
to access them (2005 California Health
Interview Survey)
California adults have greater unmet need for
MI services than the Western Region or United
States as a whole (California Department of
Mental Health)

                                                5
    Co-morbid Conditions
An extensive literature exists on the co-
occurrence of MI and substance abuse (SA)
(Williams 2003)
The Agency for Healthcare Research and
Quality (AHRQ) Clinical Classification System
(CCS) now groups both MI and SA as mental
disorder sub-categories (Duffy 2007)
The literature identifies a strong association
between MISA and injuries (Cameron 2006,
Wan 2006, Richmond 2007)

                                                 6
         Study Objectives
To describe variations in characteristics and
outcomes for California adults age 15-44 with
MI, SA, or injury
– admitted to hospital 1991-2005
– visiting the ED in 2005
To describe 15 year hospitalization trends for
MISA by age, gender and race/ethnicity
To determine race/ethnic disparities in MISA
hospital admissions over time

                                                 7
               Methods
Data Sources: CA Office of Statewide Health
Planning and Development
– Hospital patient discharges (PD) 1991-2005
– Emergency Department (ED) visits 2005
– CA Department of Finance population estimates
Analytic software: SAS
AHRQ Clinical Classification System
Data linkage: HD records linked over time to
“person” level
Patient population: Adults 15-44
                                                  8
Results: 2005 Encounters for MISA
            and Injury
  One year of data (2005) were available
  for both PD and ED encounters
  Of 604,203 hospital discharges in 2005
  – 24 % MISA (PX/SDX/DRG)
  – 13% injury
  Of 3,457,515 ED visits
  – 10% MISA
  – 29% injury
                                           9
     Demographics 2005
In both the PD and ED, men are the majority of
MISA (54% and 52% ) and injury cases (69% and
59%)
Whites represented the greatest proportion of
both PD and ED cases in all categories (50-65%)
African Americans and Whites were
disproportionately higher in the PD and ED
compared to the general population
Over half of PD and ED encounters were paid by
public insurance
                                             10
        Comparison of PD vs. ED MISA
             Diagnoses 2005
                               Column Percent Total         Percent
Clinical Classification         PD       ED         Total   Admitted

Total                       125,343   176,091   301,434         41.6

Schizophrenia/related          25.9       4.4       13.4        80.6
Affective disorder             38.4       8.4       20.9        76.5
Other psychoses                 8.6       7.6        8.0        44.8
Other mental condition          8.7      16.5       13.3        27.3
Pre-adult mental illness        0.1       0.6        0.4        15.5
Anxiety disorder                2.1      28.8       17.7         4.9
History of mental illness       0.0       1.9        1.1         1.2

Alcohol related                 6.9      21.6       15.5        18.6
Substance Related               9.1      10.2        9.7        38.9
                                                                       11
    Fifteen Year Burden
Over the 15 year period between 1991
and 2005 there were:

– 6 million discharges for MISA or injury for
  1.6 million people
– The overall rate of admission for MISA was
  94.72 in 1991 and 89.13 in 2005. This
  represents a significant overall decrease
  over the period of the study

                                                12
             Figure 1. MISA hospital admissions per 10,000 population by
                          1991-2005 by age, race and gender

Rate                                                                          Female 1991        Rate                                                                         Female 2005
  300                                                                                              300


  250                                                                                              250


  200                                    "                                                         200
                                                                                                                                                         "
                                                 "
                                                                                                                                                "
                                  "                       "
  150                                                                                              150                                                        "
                   $                                                                                                                     "      $
                                         $                                                                         $
                                  $                                                                                                      $               $
                                                 $                                                                           "    $
                                                                                                                                  "                                "
                             "                                 "                                                             $                                $
  100              "
                             $                            $                                        100                  $
                                                                                                                        "
                        "                                      $                                                   "                                                    "
                        $                                           "
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              $                                                     $         $     "
                                                                         $          $       $
                                                                                            "                 $                                                         $
              "                                                                                               "                                                                     "
    50                                                                                               50            #                                                         "
                                                                                                                                                                             $
                                                                                                                                                #        #    #                     $
                   #                     #       #        #                                                                              #                                                    $
                   !              #                            #    #         #     #                                   #    #    #                                #         #                "
                             #
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              !                                                                                               !                                                                               !
         0                                                                                                0

              10   15   20   25   30     35     40        45   50   55   60   65    70      75                10   15   20   25   30    35     40        45   50   55   60   65    70       75

                                   5-Year Age Intervals                                                                           5-Year Age Intervals

Rate                                                                               Male 1991     Rate                                                                             Male 2005
  300                                                                                              300


  250                                    "       "                                                 250                                          "        "

                                                          "                                                                                                   "
  200                             "                                                                200
                                                                                                                             "           "

  150                        "                                 "                                   150                  "         "             $                  "
                                                                                                                             $           $               $
                                  $      $
                   $                             $                                                                      $         $                           $
  100                        $                                                                     100             $
                                                          $         "                                                                                                   "
                        "
                        $                                                                                          "
                   "                                           $                                                                                                   $
                                                                         "    "
              $                          #       #                  $         $     "                                                           #        #    #         $
    50        "                                           #    #         $                           50       "                                                              "
                                  #                                                 $       $                                            #
                                                                                            "                 $    #    #         #                                #         $
                   #         #    !                                 #    #    #                                              #                                          #           "
                                                                                                                                                                                    $
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         0                                                                                                0

              10   15   20   25   30     35     40        45   50   55   60   65    70      75                10   15   20   25   30    35     40        45   50   55   60   65    70       75
                                                                                                                                                                                     13
                                   5-Year Age Intervals                                                                           5-Year Age Intervals
        Figure 2. MISA admissions per 10,000 population, by
         gender, age group, and race/ethnicity 1991 to 2005
Rate                                                                     15-24 Female Rate                                                                              15-24 Male
 300                                                                                       300

250                                                                                        250

200                                                                                        200

150                                                                  $    $     $    $
                                                                                           150                                                                 "    "
                                                               $                                                                              "     "    "                "
                         $                          "     "
                                                          $    "     "    "     "                                                  "     "                     $    $     $    "
                                                                                                                                                                               $
        $     $    $     "    $     "
                                    $    "
                                         $     "    $                                "                             $                                     $
100     "     "    "
                              "                $                                           100    $     $    $     "
                                                                                                                        $
                                                                                                                        "     "
                                                                                                                              $    $     $    $     $
                                                                                                  "     "    "
 50                                                       #    #     #    #     #    #     50                                                       #    #     #    #     #    #
        !
        #     #
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                   !     #
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                              !     !    !     !    !                                                   !    !     !    !     !    !     !    !     !    !                     !
  0                                                                                         0

       1991       1993       1995       1997       1999       2001       2003       2005         1991       1993       1995       1997       1999       2001       2003       2005

                                             Year                                                                                      Year

Rate                                                                     25-34 Female Rate                                                                              25-34 Male
 300                                                                                       300

250                                                                                        250
200                                                                                        200                     "
                                                                                                  "     "               "     "                                                "
                   "     "                                                                                   "                     "                                "     "
150     "     "               "                                      "    "                150                                                      "    "     "
                                    "    "     "          "    "                "    "
                                                                                     $                                                   "    "
                         $                          "                $    $     $                                                                                   $     $    $
        $     $    $          $     $    $                     $                                        $    $     $    $     $                                $
                                               $    $     $                                       $                                $          $     $    $
100                                                                                        100                                           $

 50                      #    #                                           #     #    #
                                                                                           50     #     #    #     #    #     #    #     #    #     #    #     #    #     #    #
        #
        !     #    #
                   !     !    !     #    #     #    #     #    #
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              !                     !    !     !    !     !
  0                                                                                         0
       1991       1993       1995       1997       1999       2001       2003       2005         1991       1993       1995       1997       1999       2001       2003     2005
                                                                                                                                                                           15
       Figure 3. Self-injury hospitalizations per 10,000, by
       gender, age group, and race/ethnicity 1991 to 2005
Rate                                                                     15-24 Female Rate                                                                          15-24 Male
  25                                                                                       25

 20                                                       $
                                                               $     $    $
                                                                                           20
                                                                                     $
              "    "     "                                                      $
                         $          "
                                    $    $
 15     "
        $     $    $          $
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                                                    $
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        !          !                     "     "          "          "                                                                                        $
 10           !               !                     "                                "     10                                                           $          $     $
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  0                                                                                        0

       1991       1993       1995       1997       1999       2001       2003       2005        1991       1993       1995       1997       1999       2001       2003       2005

                                             Year                                                                                     Year

Rate                                                                     25-34 Female Rate                                                                          25-34 Male
  25                                                                                       25

 20                                                                                        20

 15                                                                                        15
              "               $                                $     $    $
        "                "
                         $          $    $                $                     $    $
        $     $    "
                   $                           $
                              "     "          "    $                                                  "    "
 10                                      "                           "    "                10    "          $     "
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                                                                                                                             $          "                     $          $
                                                    "     "    "                                 $     $                          $
                                                                                                                                  "     $    $     $    $          $          $
                                                                                "    "                                                             "          "    "     "
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  5     !
        #     !
              #    !
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  0                                                                                        0
       1991       1993       1995       1997       1999       2001       2003       2005        1991       1993       1995       1997       1999       2001       2003       2005
                                                                                                                                                                         17
                                             Year                                                                                     Year
   Person-level relationships between
  mental illness and substance abuse by
               race/ethnicity

Race/                 Race/Ethnic Percent   MI %    SA
Ethnicity   People      MI SA BOTH           SA    % MI

White       555,845    42   28       30       51     41
Black       111,888    42   31       27       47     39
Hispanic    161,487    46   31       22       41     32
Asian        35,172    68   16       16       49     18


                                                      19
Co-occurrence of mental illness,
   substance abuse, and injury
               Person Level                        Discharge Level


            MI-SA-INJ 10%


   MI-INJ 9%
                                        MI-SA-INJ 35%
                                                                          INJ 42%
SA-INJ 7%




                              INJ 74%
                                                 MI-INJ 14%
                                                              SA-INJ 9%


                                                                             20
Average number of discharges per person
  by diagnosis group and race/ethnicity


       15

       12

           9

           6

                                                                   White
           3                                                     Black

       -
                                                           Hispanic
               Both                                      Asian
                        MISA
                                        Injury

                      White   Black   Hispanic   Asian

                                                                           21
               Conclusions
Overall MISA admission rates decrease over the
period
Men and women in the reproductive years have
the highest MISA admission rates
Racial disparities persist in rates for MISA
admissions
– Whites and Blacks are disproportionately affected
– White rates increased significantly over time while Black rates
  decreased

Self Injury rates show that whites increased
significantly and since 1999 remain the highest
rates in all age and gender subgroups
                                                                22
           Conclusions
Over time, there is a significant overlap in MI
and SA diagnoses in individuals, with 40-
50% of each group respectively also having
acute episodes of the other conditions
Fifty-eight percent of injury admissions show
co-occurrence with MI, SA or both
Persons with both MISA and injury have 2 to
5 times the total number of admissions

                                             23
       Recommendations
Conduct research to determine factors related to
changing hospitalization rates among Whites and
Blacks for MISA and INJ
Explore the relationship between access to
outpatient mental health services and PD and ED
encounters
Explore the relationship between incarceration
rates and MISA hospitalizations by race
Promote clinician screening for all persons admitted
for MI, SA or INJ for each of the other conditions
Institute long term case management for those
admitted for MISA and INJ to prevent further acute
episodes
                                                  24
   For Further Information:
Gerry Oliva, MD, MPH
– Email: olivag@fcm.ucsf.edu
Linda Remy, MSW, PhD
– Email: lremy@well.com
Mail: Family Health Outcomes Project
– 500 Parnassus Ave. Room MU-337
– San Francisco, CA 94143
Website:
http://familymedicine.medschool.ucsf.edu/fhop/

                                                 25

				
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