APHA November 2008 San Diego, CA

1. Trends in mental health and related hospitalizations in California’s reproductive age population, 1991-2005 APHA November 2008 San Diego, CA

2. 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

3. 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)

4. 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)

5. 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)

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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 Comparison of PD vs. ED MISA Diagnoses 2005

12. 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

13. Female 1991 Female 2005 Rate Rate 300 300 250 250 200 200 " " " " " " " 150 150 $ $ " $ $ $ $ $ $ $ " " " " $ " $ 100 100 $ $ " $ " " " " $ " $ " $ " $ $ " $ $ $ $ $ " $ " " " 50 50 $ " # # $ # # # # $ # # # # " # # # # ! # # # # # # ! # ! # ! ! ! ! # ! ! ! # ! # ! ! # # ! # ! ! ! ! ! ! ! ! ! ! ! ! ! ! 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 Male 1991 Male 2005 Rate Rate 300 300 " 250 250 " " " " " 200 200 " " " 150 150 " " " $ " " $ $ $ $ $ $ $ $ $ $ $ 100 100 $ $ " " " " $ $ " $ " " $ $ # # # $ # $ " # " " " 50 $ 50 # # $ # # $ $ # # $ # " # # # # # ! # " $ # # " # ! ! ! ! $ # # ! ! # ! ! ! # ! # ! ! ! ! ! # ! ! ! # ! ! ! ! ! ! ! ! ! 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 Figure 1. MISA hospital admissions per 10,000 population by 1991-2005 by age, race and gender

14. Figure 2. MISA admissions per 10,000 population, by gender, age group, and race/ethnicity 1991 to 2005

15. Figure 3. Self-injury hospitalizations per 10,000, by gender, age group, and race/ethnicity 1991 to 2005

16. 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 Person-level relationships between mental illness and substance abuse by race/ethnicity

17. MI-SA-INJ 10% MI-INJ 9% MI-SA-INJ 35% INJ 42% SA-INJ 7% INJ 74% MI-INJ 14% SA-INJ 9% Co-occurrence of mental illness, substance abuse, and injury Discharge Level Person Level

18. 15 12 9 6 White 3 Black Hispanic - Both Asian MISA Injury White Black Hispanic Asian Average number of discharges per person by diagnosis group and race/ethnicity

19. 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

20. 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

21. 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

22. 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/