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Mental Illness and Substance Use Disorders Among Veteran Clinic Users with Spinal Cord Injury

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.

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Mental Illness and Substance Use Disorders Among Veteran Clinic Users with Spinal Cord Injury

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  1. 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

  2. Background

  3. State of Research: Conflicting Views • Spinal Cord Injury (SCI) patients are at high risk for mental illnesses (MI) • depression, anxiety, post-traumatic stress disorder (PTSD) • clinical-level stress • negative consequences of physical and social functioning • SCI patients do not have elevated rates of depression

  4. Resolving the Conflicting Views • Early/acute stages may show increase in depressive symptoms • Positive effect of time on the attenuation of depressive symptoms

  5. SCI Patients have high rates of Substance Use Disorders • SCI also have high rates of SUDs • In community-based studies • 52% overall • 21% alcohol abuse • 16% marijuana use • Other studies • Prior heavy drinkers tend to drink daily • 21% drugs within the past 6-12 months

  6. SUD rates may have been high even before injury • Pre-injury use • alcohol and substance use highly correlated with the events that cause the SCI

  7. Evidence needs to be pieced No large scale studies Convenient samples used Differing time periods (immediately after injury versus many years later) Focus on PTSD /Depression No focus on all types of substances Subgroup differences not known

  8. Objectives • Document prevalence of mental illness (MI) and substance use disorders (SUD) among veterans with SCI • Estimate types of MI and SUD in SCI veterans • Examine the predictors of MI and SUD in SCI veterans

  9. Design • Veterans with SCI diagnoses in Veterans Health Administration’s (VHA) based on the Spinal Cord Dysfunction-Registry (SCD-R) • Veterans who had outpatient face-to-face utilization or hospitalization either in the VHA, the Medicare fee-for-service or both systems • Longitudinal cohort from fiscal years (FY) 1999 to 2002

  10. Research Design SCD-R N=36,987 • Merged SCD-R with VHA data • (current use: FY1999-2002) 1 VHA Admin Medicare FFS Merged data 2 2. Merged VHA with Medicare (FFS) utilization

  11. Study Population(N = 8,338) Inclusions Valid Onset date Onset before study period (FY 1999) Alive during entire study (FY 1999-2002) Utilization in VA or Medicare or both Final dataset N=8,338

  12. Missing data • In the registry : ICD-9-CM diagnostic codes from VHA and Medicare were used • In demographics: missing in VHA was replaced by Medicare. When missing from all sources it was used as a separate category in regressions.

  13. Measures

  14. Dependent Variables(FY 2000-2001) • Mental Illness and Substance Use Disorder(MI/SUD)Categories (ICD-9-CM codes) • MI:schizophrenia, depressive disorders, bipolar and other psychoses, anxiety and PTSD • 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%)

  15. Independent Variables

  16. Statistical Procedures • Chi-square tests • bivariate associations between MI/SUD categories and the independent variables. • Multinomial logistic regression • the predictors of the MI/SUD categories. • adjusted odds ratios at 95% CI. • p-value < 0.01

  17. Results

  18. Description of Study population (%)(N = 8,338)

  19. Depression was very common ANY MI = 34%

  20. Tobacco use was very common Any SUD = 26.3%

  21. Mental illness by substances used

  22. MI/SUD Categories • MI/SUD categories were constructed broadly by combining MI and SUD and included 4 groups: • No MI/SUD • MI only • SUD only • MI/SUD both

  23. Over 2 years, 46% had either MI and/or SUD BOTH SUD ONLY NONE MI ONLY

  24. 100% 14.5 15.9 16.7 18.0 18.3 27.0 80% 9.4 12.0 11.7 10.3 13.0 15.5 28.0 60% 23.8 25.7 23.0 31.1 25.2 40% 48.1 47.9 46.5 46.0 20% 40.3 32.3 0% COPD DM Heart HTN UTI Skin Disease Ulcer None MI only SUD ony MI/SUD Rates of mental illness and/or SUD varied by co-morbid conditions

  25. Skin ulcer UTI COPD Heart Dis. Hypertension Multinomial Logistic Regression Comorbidities Diabetes Depression SUD Only * MI Only * MI/SUD * * P <.001

  26. Adjusted Odds Ratios Multinomial Logistic Regression African Americans and Latinos African American African American Latino Latino

  27. Adjusted Odds RatiosMultinomial Logistic Regression Duration of SCI 10-19 yrs 20-29 yrs 30 plus yrs

  28. Conclusions • Among veterans with SCI, the prevalence of MI or SUD or both was high (47%) • higher than the 15% in earlier study (Radnitz et al., 1996). • Depressive disorders (27%) were comparable to a recent study of SCI veterans over a three year period (Smith et al., 2007) • Our findings revealed that depressive disorders were the most common diagnoses. All other diagnoses were present in less than 10% of the population.

  29. Conclusions • The association of MI or SUD and physical illnesses in SCI patients was dependent on the type of illness • diabetes were more likely to have depression • Skin Ulcer, COPD and hypertension were strongly associated with MI or SUD in all combinations • UTI and heart disease were significantly associated with either MI or both MI/SUD.

  30. Conclusions • African Americans were less likely to have MI only • Duration SCI was protective – progressive decrease in MI and/or SUD • Paraplegia patients have more SUD • Chronic illness – patterns of MI/SUD were different

  31. Implications • Newer SCI patients have depression after the rehabilitation phase, but that does abate over time (Richards, 1986; Kennedy & Rogers, 2000). • Regular screening of depression among SCI for early detection and treatment during hospitalization, rehab and outpatient therapies • Targeted efforts for tobacco use cessation and counseling • High rates of psychiatric conditions and SUDs, specifically among those with a chronic physical illness suggest • significantly high expenditures and • challenges to chronic illness management in the SCI population

  32. Limitations • Temporal process of MI can not be tested • Pre-injury SUD is very high • High attrition of study population due to missing on-set date • MI and SUD may be under-coded • Ours may be considered as a lower-bound estimate

  33. Strengths • Our study highlights the complexity of illness burden in the SCI veteran population • Subgroup differences in MI/SUD found • Large scale study • Differing time periods (immediately after injury versus many years later) • Focus on the gamut of MI and SUD • includes schizophrenia to anxiety disorders • includes smoking

  34. Special Thanks to Patricia Findley, DrPH, MSW Bridget Smith, PhD

  35. Thank youon behalf of a special population

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