Christopher N. Kaufmann

Service Use and Barriers to Mental Health Care Among Adults With Major Depression and Comorbid Substance Dependence

OBJECTIVE The study explored mental health service use patterns and barriers to care among individuals with comorbid mental and substance use disorders. METHODS Using data from the National Survey on Drug Use and Health (2005-2010) for 18,972 adults with past-year major depressive episodes, the study compared mental health service use and perceived barriers to care among participants with and without co-occurring alcohol dependence, nonalcohol drug dependence, and both alcohol and drug dependence. RESULTS Compared with participants without comorbid substance dependence, participants with alcohol dependence or both alcohol and nonalcohol drug dependence used more mental health services of all types, and participants with only comorbid alcohol dependence used more medication treatments. Participants with comorbid substance dependence were significantly more likely than those without comorbid substance dependence to report unmet mental health treatment need. However, barriers to mental health care were remarkably similar across groups, with financial barriers being the most common in all groups. CONCLUSIONS Participants with major depression comorbid with substance dependence used more mental health services but also perceived more unmet need for such care than individuals without such comorbidity. However, barriers to mental health care were similar across groups with and without comorbidity. Policies aimed at expanding insurance coverage and mental health parity would likely benefit individuals with major depression and substance dependence comorbidity even more than those without such comorbidity.

Comparing barriers to mental health treatment and substance use disorder treatment among individuals with comorbid major depression and substance use disorders.

Barriers to both mental health and substance use disorder treatments have rarely been examined among individuals with comorbid mental health and substance use disorders. In a sample of 393 adults with 12-month major depressive episodes and substance use disorders, we compared perceived barriers to these two types of treatments. Data were drawn from the 2005-2011 U.S. National Surveys on Drug Use and Health. Overall, the same individuals experienced different barriers to mental health treatment versus substance use disorder treatment. Concerns about negative views of the community, effects on job, and inconvenience of services were more commonly reported as reasons for not receiving substance use disorder treatment. Not affording the cost of care was the most common barrier to both types of treatments, but more commonly reported as a barrier to mental health treatment. Improved financial access through the Affordable Care Act and parity legislation and integration of mental health and substance use disorder services may help to reduce treatment barriers among individuals with comorbid mental health and substance disorders.

Co-occurring Conditions and Change in Diagnosis in Autism Spectrum Disorders

OBJECTIVE: This study aimed to investigate descriptive characteristics and co-occurring neurodevelopmental and psychiatric conditions in young children, children, and adolescents with a current and consistent or past but not current (PBNC) diagnosis of autism spectrum disorder (ASD) and how such characteristics and conditions may engender a change in diagnosis of an ASD. METHODS: Cross-sectional data of 1366 children with a parent-reported current or PBNC ASD diagnosis were obtained from the National Survey of Children’s Health 2007 data set across 3 developmental stages: young children (aged 3–5 years), children (aged 6–11 years), and adolescents (aged 12–17 years). Multinomial logistic regression was used to examine demographic characteristics and co-occurring conditions that differentiate the groups with a current ASD from groups with a PBNC ASD. RESULTS: Results indicated the co-occurring conditions that distinguish groups currently diagnosed with an ASD from groups with a PBNC ASD diagnosis. In young children, current moderate/severe learning disability, and current moderate/severe developmental delay; in children, past speech problem, current moderate/severe anxiety, and past hearing problem; and in adolescents, current moderate/severe speech problem, current mild seizure/epilepsy, and past hearing problem. CONCLUSIONS: These findings suggest that the presence of co-occurring psychiatric and neurodevelopmental conditions are associated with a change in ASD diagnosis. Questions remain as to whether changes in diagnosis of an ASD are due to true etiologic differences or shifts in diagnostic determination.

Insomnia and Health Services Utilization in Middle-Aged and Older Adults: Results From the Health and Retirement Study

BACKGROUND Complaints of poor sleep are common among older adults. We investigated the prospective association between insomnia symptoms and hospitalization, use of home health care services, use of nursing homes, and use of any of these services in a population-based study of middle-aged and older adults. METHODS We studied 14,355 adults aged 55 and older enrolled in the 2006 and 2008 waves of the Health and Retirement Study. Logistic regression was used to study the association between insomnia symptoms (0, 1, or ≥ 2) in 2006 and reports of health service utilization in 2008, after adjustment for demographic and clinical characteristics. RESULTS Compared with respondents reporting no insomnia symptoms, those reporting one symptom had a greater odds of hospitalization (adjusted odds ratio [AOR] = 1.28, 95% confidence interval [CI] = 1.15-1.43, p < .001), use of home health care services (AOR = 1.29, 95% CI = 1.09-1.52, p = .004), and any health service use (AOR = 1.28, 95% CI = 1.15-1.41, p < .001). Those reporting greater than or equal to two insomnia symptoms had a greater odds of hospitalization (AOR = 1.71, 95% CI = 1.50-1.96, p < .001), use of home health care services (AOR = 1.64, 95% CI = 1.32-2.04, p < .001), nursing home use (AOR = 1.45, 95% CI = 1.10-1.90, p = .009), and any health service use (AOR = 1.72, 95% CI = 1.51-1.95, p < .001) after controlling for demographics. These associations weakened, and in some cases were no longer statistically significant, after adjustment for clinical covariates. CONCLUSIONS In this study, insomnia symptoms experienced by middle-aged and older adults were associated with greater future use of costly health services. Our findings raise the question of whether treating or preventing insomnia in older adults may reduce use of and spending on health services among this population.

Trends in prescribing of sedative-hypnotic medications in the USA: 1993–2010

Non‐benzodiazepine receptor agonists (nBZRAs) were developed as an alternative to benzodiazepines (BZDs) to treat insomnia. Little is known about how the introduction of nBZRAs influenced trends in BZD prescribing. We examined BZD and nBZRA prescribing trends from 1993 to 2010.

Association Between Insomnia Symptoms and Functional Status in U.S. Older Adults

OBJECTIVES We studied the association between insomnia symptoms and late-life functioning, including physical capacity, limitations in household activities, and participation in valued activities. METHODS Participants were 6,050 adults independent in self-care activities from a representative sample of older Medicare beneficiaries. They completed objective measures of physical capacity and self-report measures of insomnia symptoms, help and difficulty with household activities, and participation in valued activities. RESULTS After adjustment, insomnia symptoms were associated with a greater odds of receiving help or having difficulty with selected household activities (laundry, shopping), greater odds of help or difficulty with ≥ 1 household activity [1 symptom vs. 0, odds ratio (OR)=1.27, p < .05; 2 symptoms vs. 0, OR = 1.35, p < .01), and of restricted participation in specific valued activities (attending religious services, going out for enjoyment) and in ≥ 1 valued activity (1 symptom vs. 0, OR = 1.29, p < .05; 2 symptoms vs. 0, OR = 1.50, p < .01). There was no independent association between insomnia symptoms and physical capacity. DISCUSSION Among older adults, insomnia symptoms are associated with a greater odds of limitation in household activities and of restricted participation in valued activities. Insomnia interventions may improve functioning and quality of life among elders.

Prescriptions, nonmedical use, and emergency department visits involving prescription stimulants.

OBJECTIVE Little is known regarding the temporal trends in prescriptions, nonmedical use, and emergency department (ED) visits involving prescription stimulants in the United States. Our aim was to examine these 3 national trends involving dextroamphetamine-amphetamine and methylphenidate in adults and adolescents. METHOD Three national surveys conducted between 2006-2011 were used: National Disease and Therapeutic Index, a survey of office-based practices; National Survey on Drug Use and Health, a population survey of substance use; and Drug Abuse Warning Network, a survey of ED visits. Ordinary least squares regression was used to examine temporal changes over time and the associations between the 3 trends. RESULTS In adolescents, treatment visits involving dextroamphetamine-amphetamine and methylphenidate decreased over time; nonmedical dextroamphetamine-amphetamine use remained stable, while nonmedical methylphenidate use declined by 54.4% in 6 years. ED visits involving either medication remained stable. In adults, treatment visits involving dextroamphetamine-amphetamine remained unchanged, while nonmedical use went up by 67.1% and ED visits went up by 155.9%. These 3 trends involving methylphenidate remained unchanged. Across age groups, the major source for nonmedical use of both medications was a friend or relative; two-thirds of these friends and relatives had obtained the medication from a physician. CONCLUSIONS Trends in prescriptions for stimulants do not correspond to trends in reports of nonmedical use and ED visits. Increased nonmedical stimulant use may not be simply attributed to increased prescribing trends. Future studies should focus on deeper understanding of the proportion of, risk factors for, and motivations for drug diversions.

Binge drinking and insomnia in middle-aged and older adults: the Health and Retirement Study

Alcohol use in later life has been linked to poor sleep. However, the association between binge drinking, which is common among middle‐aged and older adults, and insomnia has not been previously assessed.

Racial/Ethnic Differences in Insomnia Trajectories Among U.S. Older Adults

OBJECTIVES Insomnia is reported to be more prevalent in minority racial/ethnic groups. Little is known, however, about racial/ethnic differences in changes in insomnia severity over time, particularly among older adults. We examined racial/ethnic differences in trajectories of insomnia severity among middle-aged and older adults. DESIGN Data were drawn from five waves of the Health and Retirement Study (2002-2010), a nationally representative longitudinal biennial survey of adults aged > 50 years. SETTING Population-based. PARTICIPANTS 22,252 participants from non-Hispanic white, non-Hispanic black, Hispanic, and other racial/ethnic groups. MEASUREMENTS Participants reported the severity of four insomnia symptoms; summed scores ranged from 4 (no insomnia) to 12 (severe insomnia). We assessed change in insomnia across the five waves as a function of race/ethnicity. RESULTS Across all participants, insomnia severity scores increased 0.19 points (95% CI: 0.14-0.24; t = 7.52; design df = 56; p < 0.001) over time after adjustment for sex, race/ethnicity, education, and baseline age. After adjusting for the number of accumulated health conditions and body mass index, this trend decreased substantially and even changed direction (B = -0.24; 95% CI: -0.29 to -0.19; t = -9.22; design df = 56; p < 0.001). The increasing trajectory was significantly more pronounced in Hispanics compared with non-Hispanic whites, even after adjustment for number of accumulated health conditions, body mass index, and number of depressive symptoms. CONCLUSIONS Although insomnia severity increases with age-largely due to the accumulation of health conditions-this trend appears more pronounced among Hispanic older adults than in non-Hispanic whites. Further research is needed to determine the reasons for a different insomnia trajectory among Hispanics.

Diabetes and cognitive outcomes in a nationally representative sample: the National Health and Aging Trends Study

BACKGROUND The prevalence of both type II diabetes mellitus (DM) and cognitive impairment is high and increasing in older adults. We examined the extent to which DM diagnosis was associated with poorer cognitive performance and dementia diagnosis in a population-based cohort of US older adults. METHODS We studied 7,606 participants in the National Health and Aging Trends Study, a nationally representative cohort of Medicare beneficiaries aged 65 years and older. DM and dementia diagnosis were based on self-report from participants or proxy respondents, and participants completed a word-list memory test, the Clock Drawing Test, and gave a subjective assessment of their own memory. RESULTS In unadjusted analyses, self-reported DM diagnosis was associated with poorer immediate and delayed word recall, worse performance on the Clock Drawing Test, and poorer self-rated memory. After adjusting for demographic characteristics, body mass index, depression and anxiety symptoms, and medical conditions, DM was associated with poorer immediate and delayed word recall and poorer self-rated memory, but not with the Clock Drawing Test performance or self-reported dementia diagnosis. After excluding participants with a history of stroke, DM diagnosis was associated with poorer immediate and delayed word recall and the Clock Drawing Test performance, and poorer self-rated memory, but not with self-reported dementia diagnosis. CONCLUSIONS In this recent representative sample of older Medicare enrollees, self-reported DM was associated with poorer cognitive test performance. Findings provide further support for DM as a potential risk factor for poor cognitive outcomes. Studies are needed that investigate whether DM treatment prevents cognitive decline.