Laura A. Pratt

Characteristics of primary care visits for individuals with severe mental illness in a national sample

Individuals with severe mental illness (SMI) are at risk for inadequate general medical and preventive care, but little is known about their visits for primary care. We performed a cross-sectional analysis of primary care physician visits from the National Ambulatory Medical Care Survey (NAMCS) 1993-1998 and compared visit characteristics for patients with and without SMI. SMI was defined from ICD-9 diagnoses and medications. Primary care visits for patients with SMI were more likely to be return visits, were longer, and were more likely to have scheduled follow-up than for patients without SMI. Obesity, diabetes, and smoking were reported approximately twice as frequently in visits for patients with SMI compared to patients without SMI. The percent of visits with preventive counseling and counseling targeted at chronic medical conditions was similar for both groups. Likely appropriate to their complex needs, patients with SMI using primary care tend to have more return visits, longer time with the physician and are more often scheduled for follow-up care; their preventive counseling appears similar to non-SMI visits.

The association of depression, risky sexual behaviours and herpes simplex virus type 2 in adults in NHANES, 2005–2008

Objectives Depression has been linked to risky sexual behaviours in adolescents, but there is little research among adults. The goal of this analysis was to examine the associations between current depression and self-reported risky sexual behaviours in a nationally representative sample of US adults aged 20–59 years. The authors also examined the association between depression and infection with herpes simplex virus type 2 (HSV-2), a biological marker of risky sexual behaviours. Methods The authors used data from the 2005–2008 National Health and Nutrition Examination Surveys. Current depression was measured by the Patient Health Questionnaire-9. Antibodies to HSV-2 were tested using the enzymatic immunodot assay. The authors used logistic regression to examine the associations controlling for socio-demographic variables. Results Among 5273 adults aged 20–59 years, 7% had depression, 36% reported 10 or more lifetime sex partners, 15% had two or more past-year sex partners and 13% had first sex before 15 years of age. Persons with each of the risky sexual behaviours were more likely to have depression than those without. In stratified analyses, risky sexual behaviours were associated with depression in women but not in men. Among 3940 adults aged 20–49 years, 19% had HSV-2 infection. Persons with HSV-2 infection were more likely to have depression (OR 2.1, 95% CI 1.5 to 2.9). Conclusions Risky sexual behaviour is related to current depression in adult women. Healthcare providers should be aware of this association and its potential implications in order to deliver better care for patients with depression or sexually transmitted infections.

Excess mortality due to depression and anxiety in the United States: results from a nationally representative survey

OBJECTIVES We compared the mortality of persons with and without anxiety and depression in a nationally representative survey and examined the role of socioeconomic factors, chronic diseases and health behaviors in explaining excess mortality. METHODS The 1999 National Health Interview Survey was linked with mortality data through 2011. We calculated the hazard ratio (HR) for mortality by presence or absence of anxiety/depression and evaluated potential mediators. We calculated the population attributable risk of mortality for anxiety/depression. RESULTS Persons with anxiety/depression died 7.9 years earlier than other persons. At a population level, 3.5% of deaths were attributable to anxiety/depression. Adjusting for demographic factors, anxiety/depression was associated with an elevated risk of mortality [HR=1.61, 95% confidence interval (CI)=1.40, 1.84]. Chronic diseases and health behaviors explained much of the elevated risk. Adjusting for demographic factors, people with past-year contact with a mental health professional did not demonstrate excess mortality associated with anxiety/depression while those without contact did. CONCLUSIONS Anxiety/depression presents a mortality burden at both individual and population levels. Our findings are consistent with targeting health behaviors and physical illnesses as strategies for reducing this excess mortality among people with anxiety/depression.

Excess mortality among people who report lifetime use of illegal drugs in the United States: A 20-year follow-up of a nationally representative survey

OBJECTIVE The purpose of this study was to determine the mortality risks, over 20 years of follow-up in a nationally representative sample, associated with illegal drug use and to describe risk factors for mortality. METHODS We analyzed data from the 1991 National Health Interview Survey, which is a nationally representative household survey in the United States, linked to the National Death Index through 2011. This study included 20,498 adults, aged 18-44 years in 1991, with 1047 subsequent deaths. A composite variable of self-reported lifetime illegal drug use was created (hierarchical categories of heroin, cocaine, hallucinogens/inhalants, and marijuana use). RESULTS Mortality risk was significantly elevated among individuals who reported lifetime use of heroin (HR=2.40, 95% CI: 1.65-3.48) and cocaine (HR=1.27, 95% CI: 1.04-1.55), but not for those who used hallucinogens/inhalants or marijuana, when adjusting for demographic characteristics. Baseline health risk factors (smoking, alcohol use, physical activity, and BMI) explained the greatest amount of this mortality risk. After adjusting for all baseline covariates, the association between heroin or cocaine use and mortality approached significance. In models adjusted for demographics, people who reported lifetime use of heroin or cocaine had an elevated mortality risk due to external causes (poisoning, suicide, homicide, and unintentional injury). People who had used heroin, cocaine, or hallucinogens/inhalants had an elevated mortality risk due to infectious diseases. CONCLUSIONS Heroin and cocaine are associated with considerable excess mortality, particularly due to external causes and infectious diseases. This association can be explained mainly by health risk behaviors.

Implications of two-stage depression screening for identifying persons with thoughts of self-harm

OBJECTIVE Persons with thoughts of self-harm may need evaluation for suicide risk. We examine the prevalence of thoughts of self-harm and whether persons with thoughts of self-harm are identified when two-stage depression screening is used. METHODS Data are from the 2005-2010 National Health and Nutrition Examination Surveys. Persons responding positively to question nine of the Patient Health Questionnaire-9 (PHQ-9) are identified as having thoughts of self-harm. We compare two depression cutoff scores for the Patient Health Questionnaire-2 (PHQ-2) to see what percentage of persons with thoughts of self-harm would be identified as needing further screening with the PHQ-9. RESULTS The prevalence of thoughts of self-harm was 3.5%. Persons 12-17 years old, poor and reporting fair or poor health were more likely to report thoughts of self-harm. A cutoff score of three on the PHQ-2 identified 49% of persons with thoughts of self-harm for further screening with the PHQ-9. A cut point of two increased the proportion of persons with thoughts of self-harm continuing for further screening to 76%. CONCLUSIONS Using a lower cutoff score, two, the PHQ-2 captures more persons with thoughts of self-harm. One quarter of persons with self-harm thoughts may not be identified for further screening when two-stage screening is used.