Rani A. Hoff

Social and physical health risk factors for first-onset major depressive disorder in a community sample

Using prospective data on 3,170 respondents aged 18 years and over who were at risk for a first-onset major depression from the New Haven site of the Epidemiologic Catchment Area (ECA) study, these analyses assessed the effects of social status, physical health status, and social isolation on first-onset depression in a 1-year. period, controlling for demographic characteristics and baseline psychiatric factors. Among the assessed potential risk factors, poverty status [odds ratio (OR=2.034,P<0.05)] and confinement to a bed or chair (OR=4.015,P<0.05) were independently associated with an increased risk for a first-onset depressiveepisode when controlling for gender, age, past history of substance abuse, and subclinical depressive symptoms. The effects of poverly, and to a lesser degree homebound status, were substantially reduced when controlling for degree of isolation from friends and family, suggesting that social isolation mediates some of the relationships between social and physical statuses and major depression.

LONG-TERM PATTERNS OF SERVICE USE AND COST AMONG PATIENTS WITH BOTH PSYCHIATRIC AND SUBSTANCE ABUSE DISORDERS

OBJECTIVES This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.

FEMALE VETERANS' USE OF DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SERVICES

OBJECTIVES As access of women to mental health services has become increasingly important, empirical research has begun to examine the determinants of mental health care utilization across gender. This article examines the effect of being an extreme minority on utilization of Department of Veterans Affairs (VA) health services by female veterans. METHODS Data were collected on a representative national sample of veterans in 1992 as part of the National Survey of Veterans. These data included information on sociodemographic variables, military service variables, physical health and disability, and health services utilization. The authors examined whether women who used health services in 1992, and who were eligible for VA care, differed from men on the likelihood of using any VA health services and on the likelihood of use of VA outpatient and inpatient health services. In addition, we compared VA health care utilization among subgroups of veterans with physical and mental disorders, and compared self-reported reasons for choice of health care provider, across gender. RESULTS Results indicated that female veterans were less likely than male veterans to use VA health services. This difference was explained by lower utilization by women of VA outpatient services, since inpatient admission rates were the same across gender. The lower outpatient utilization was specific to women with self-reported mental disorders. Women with physical conditions did not differ from men with similar conditions in their VA outpatient utilization. Finally, men and women did not differ on their reasons for choosing VA or non-VA care. CONCLUSIONS The authors conclude that extreme gender minority status appears to affect outpatient utilization rates at the VA among women with mental disorders, perhaps because of the more personal or sensitive nature of the services involved. Further research is needed to understand why certain women may be underutilizing VA outpatient services and on the consequences of minority gender status for health service utilization, more generally.

Impulsivity, Sensation-Seeking, and Part-Time Job Status in Relation to Substance Use and Gambling in Adolescents

PURPOSE Although impulsivity, sensation-seeking, and part-time employment have each been linked to risky behaviors in adolescents, their inter-relationships are less well-understood. We examined data from adolescents to assess the following predictions: (1) sensation-seeking would relate closely to substance use and gambling; (2) impulsivity would relate closely to alcohol, drug, and gambling problems; and (3) these relationships would be particularly strong among those holding part-time jobs. METHOD High-school students (N = 3,106) were surveyed to provide data on impulsivity, sensation-seeking, and part-time job status. Bivariate and logistic regression analyses were conducted to examine relationships with gambling, substance use (i.e., alcohol, cigarettes, and marijuana) and related problems. RESULTS Both impulsivity and sensation-seeking related significantly to substance use and impulsivity to gambling. Impulsivity had stronger associations with drug and gambling problems than sensation-seeking did. Students with paid part-time jobs were more likely to drink alcohol, binge drink, and use marijuana. Sensation-seeking had a particularly strong relationship to heavy cigarette smoking among students with part-time jobs. Conversely, there was little relationship between part-time job status and smoking among low sensation-seekers. CONCLUSIONS These findings further support the relevance of sensation-seeking, impulsivity, and part-time job status to risky behaviors among adolescents. Sensation-seeking and impulsivity had unique relationships to risky behaviors, in accordance with theory and prior evidence. Impulsive adolescents may be in particular need for interventions to reduce drug use and gambling. Although part-time jobs can be beneficial, parents and caregivers should be mindful of potential negative ramifications of paid work outside the home.

Cross-system service use among psychiatric patients: data from the Department of Veterans Affairs.

This study examines the cross-system use of non-Department of Veterans Affairs (VA) services in a sample of psychiatric patients from the VA in 1990. Data were collected over a two-week period on all mental health outpatients and included demographic information, diagnoses, and self-reported use of non-VA services in the previous two weeks and six months. In the entire sample, 10.6% and 23.3% reported cross-system use in the previous two weeks and six months, respectively. Predictors of cross-system use were lower VA utilization, a nonschizophrenic diagnosis, not having a VA service-connected disability, and being female. These data indicate that a substantial proportion of VA mental health patients are using non-VA services. Utilization patterns indicate that they may be substituting non-VA for VA services. These results are unlikely to be unique to VA, and rates of cross-system use will likely increase in all health care systems as financial restrictions increase.

Previous Use of Alcohol, Cigarettes, and Marijuana and Subsequent Abuse of Prescription Opioids in Young Adults

PURPOSE There has been an increase in the abuse of prescription opioids, especially in younger individuals. The current study explores the association between alcohol, cigarette, and/or marijuana use during adolescence and subsequent abuse of prescription opioids during young adulthood. METHODS We used demographic/clinical data from community-dwelling individuals in the 2006-2008 National Survey on Drug Use and Health. We used logistic regression analyses, adjusted for these characteristics, to test whether having previous alcohol, cigarette, or marijuana use was associated with an increased likelihood of subsequently abusing prescription opioids. RESULTS Twelve percent of the survey population of 18-25 year olds (n = 6,496) reported current abuse of prescription opioids. For this population, prevalence of previous substance use was 57% for alcohol, 56% for cigarettes, and 34% for marijuana. We found previous alcohol use was associated with the subsequent abuse of prescription opioids in young men but not young women. Among both men and women, previous marijuana use was 2.5 times more likely than no previous marijuana to be associated with subsequent abuse of prescription opioids. We found that among young boys, all previous substance use (alcohol, cigarettes, and marijuana), but only previous marijuana use in young girls, was associated with an increased likelihood of subsequent abuse of prescription opioids during young adulthood. CONCLUSIONS Previous alcohol, cigarette, and marijuana use were each associated with current abuse of prescription opioids in 18-25-year-old men, but only marijuana use was associated with subsequent abuse of prescription opioids in young women. Prevention efforts targeting early substance abuse may help to curb the abuse of prescription opioids.

The use of VA and non-VA mental health services by female veterans.

OBJECTIVES This study compared Department of Veterans Affairs (VA) and non-VA mental health service use among male and female veterans. Because female veterans are a distinct minority in VA, it was hypothesized that they would be less likely to use VA mental health care than would male veterans. METHODS Using data from a national sample of Vietnam and Vietnam-era male (n = 1,612) and female (n = 736) veterans, the following were examined: (1) gender differences in use of VA mental health services, (2) gender differences in use of non-VA mental health services, and (3) differences in utilization of mental health services across subgroups defined by psychiatric diagnosis, adjusting for sociodemographic and need variables. RESULTS Female veterans were equally likely to use VA mental health services as male veterans, but were substantially more likely to use non-VA mental health services. This suggests that the demand for mental health services overall is substantially greater among female veterans than among male veterans and, by implication, that the equal levels of observed VA service use actually represent underutilization of VA services on the part of female veterans. Logistic regression models showed that these utilization patterns were consistent across diagnostic subgroups. CONCLUSIONS Special efforts, such as the development of womens specialty mental health clinics, may be needed to enhance the acceptability of VA mental health services to female veterans. This study also highlights the importance of considering overall demand for services in addition to more objective diagnostic data in evaluating the adequacy of service delivery and its accessibility.

Mental disorder as a risk factor for human immunodeficiency virus infection in a sample of veterans.

People who suffer from mental disorders are at increased risk for becoming infected with HIV. There have been no studies that show whether particular psychiatric disorders present an increased risk for HIV infection in samples of nonpatients. This article uses data from the 1992 National Survey of Veterans to determine if veterans with posttraumatic stress disorder (PTSD), or with other mental or emotional problems, are at increased risk for HIV infection. The results indicate that the combination of PTSD and substance abuse increased the risk of HIV infection by almost 12 times over those without either. This is evidence of a particular psychiatric disorder increasing risk for HIV. Although cross-sectional, these data allow some conjecture about the timing of the onset of PTSD in relation to HIV infection. These results present powerful evidence that mentally ill persons such as those with PTSD, who may be underserved for health services including AIDS prevention efforts, should be targeted as an at-risk group.

The musculoskeletal diagnosis cohort: Examining pain and pain care among veterans

Abstract Musculoskeletal disorders (MSDs) are highly prevalent, painful, and costly disorders. The MSD Cohort was created to characterize variation in pain, comorbidities, treatment, and outcomes among patients with MSD receiving Veterans Health Administration care across demographic groups, geographic regions, and facilities. We searched electronic health records to identify patients treated in Veterans Health Administration who had ICD-9-CM codes for diagnoses including, but not limited to, joint, back, and neck disorders, and osteoarthritis. Cohort inclusion criteria were 2 or more outpatient visits occurring within 18 months of one another or one inpatient visit with an MSD diagnosis between 2000 and 2011. The first diagnosis is the index date. Pain intensity numeric rating scale (NRS) scores, comorbid medical and mental health diagnoses, pain-related treatments, and other characteristics were collected retrospectively and prospectively. The cohort included 5,237,763 patients; their mean age was 59, 6% were women, 15% identified as black, and 18% reported severe pain (NRS ≥ 7) on the index date. Nontraumatic joint disorder (27%), back disorder (25%), and osteoarthritis (21%) were the most common MSD diagnoses. Patients entering the cohort in recent years had more concurrent MSD diagnoses and higher NRS scores. The MSD Cohort is a rich resource for collaborative pain-relevant health service research.

A formative evaluation of two evidence-based psychotherapies for PTSD in VA residential treatment programs.

Between July 2008 and March 2011, 38 U.S. Department of Veterans Affairs (VA) residential treatment programs for posttraumatic stress disorder (PTSD) participated in a formative evaluation of their programmatic services, including evidenced-based treatments (EBTs). Face-to-face qualitative interviews were conducted with over 250 staff by an independent psychologist along with onsite participant observations. This evaluation coincided with a national VA dissemination initiative to train providers in two EBTs for PTSD: prolonged exposure (PE) and cognitive processing therapy (CPT). A substantial proportion of eligible (based on professional background) residential treatment providers received training in PE (37.4%) or CPT (64.2%), with 9.5% completing case consultation or becoming national trainers in each therapy respectively. In semistructured interviews, providers reported that their clinical programs had adopted these EBTs at varying levels ranging from no adoption to every patient receiving the full protocol. Suggestions for improving the adoption of PE and CPT are noted, including distilling manualized treatments to essential common elements.