Mental Illness and Substance Use Mental Illness and Substance Use Disorders Among Veteran Clinic Users Disorders Among Veteran Clinic Users

with Spinal Cord Injurywith Spinal Cord Injury

Ranjana Banerjea, PhDRanjana Banerjea, PhDUsha Sambamoorthi, PhDUsha Sambamoorthi, PhD

Leonard M Pogach, MD, MBALeonard M Pogach, MD, MBAFrances Weaver, PhD Frances Weaver, PhD Thomas Findley, MDThomas Findley, MD

Veterans Health Administration, East OrangeVeterans Health Administration, East Orange

BackgroundBackground

State of Research: State of Research: Conflicting ViewsConflicting Views

Spinal Cord Injury (SCI) patients Spinal Cord Injury (SCI) patients are are at high riskat high risk for mental illnesses (MI) for mental illnesses (MI)– depression, anxiety, post-traumatic depression, anxiety, post-traumatic

stress disorder (PTSD)stress disorder (PTSD)– clinical-level stressclinical-level stress– negative consequences of physical and negative consequences of physical and

social functioning social functioning

SCI patients SCI patients do notdo not have elevated have elevated rates of depressionrates of depression

Resolving the Resolving the Conflicting ViewsConflicting Views

Early/acute stages may show Early/acute stages may show increase in depressive symptoms increase in depressive symptoms

Positive effect of time on the Positive effect of time on the attenuation of depressive attenuation of depressive symptoms symptoms

SCI Patients have SCI Patients have highhigh rates rates of Substance Use Disordersof Substance Use Disorders

SCI also SCI also have have high rates ofhigh rates of SUDs SUDs– In community-based studiesIn community-based studies

52% overall 52% overall

21% alcohol abuse 21% alcohol abuse

16% marijuana use 16% marijuana use

– Other studies Other studies

Prior heavy drinkers tend to drink daily Prior heavy drinkers tend to drink daily

21% drugs within the past 6-12 months21% drugs within the past 6-12 months

SUD rates may have been high SUD rates may have been high even before injuryeven before injury

Pre-injury usePre-injury use– alcohol and substance use alcohol and substance use highly highly

correlatedcorrelated with the events that cause with the events that cause the SCIthe SCI

Evidence needs to be piecedEvidence needs to be pieced

No large scale studiesNo large scale studiesConvenient samples usedConvenient samples usedDiffering time periods (immediately Differing time periods (immediately after injury versus many years later)after injury versus many years later)Focus on PTSD /DepressionFocus on PTSD /DepressionNo focus on all types of substances No focus on all types of substances Subgroup differences not knownSubgroup differences not known

ObjectivesObjectives

Document Document prevalenceprevalence of mental illness of mental illness (MI) and substance use disorders (MI) and substance use disorders (SUD) among veterans with SCI (SUD) among veterans with SCI

Estimate Estimate typestypes of MI and SUD in SCI of MI and SUD in SCI veteransveterans

Examine the Examine the predictorspredictors of MI and SUD of MI and SUD in SCI veteransin SCI veterans

DesignDesignVeterans with SCI diagnoses in Veterans Veterans with SCI diagnoses in Veterans Health Administration’s (VHA) based on Health Administration’s (VHA) based on the Spinal Cord Dysfunction-Registry the Spinal Cord Dysfunction-Registry (SCD-R)(SCD-R)

Veterans who had outpatient face-to-face Veterans who had outpatient face-to-face utilization or hospitalization either in the utilization or hospitalization either in the VHA, the Medicare fee-for-service or both VHA, the Medicare fee-for-service or both systemssystems

Longitudinal cohort from fiscal years (FY) Longitudinal cohort from fiscal years (FY) 1999 to 2002 1999 to 2002

Research DesignResearch Design

SCD-RN=36,987

VHA Admin

MedicareFFS

2. Merged VHA with Medicare (FFS) utilization

1. Merged SCD-R with VHA data

(current use: FY1999-2002)

Merged data

2

1

Study PopulationStudy Population(N = 8,338)(N = 8,338)

InclusionsValid Onset date

Onset before study period (FY 1999)Alive during entire study (FY 1999-2002)

Utilization in VA or Medicare or both

Final datasetN=8,338

Missing dataMissing data

In the registry : ICD-9-CM diagnostic In the registry : ICD-9-CM diagnostic codes from VHA and Medicare were usedcodes from VHA and Medicare were used

In demographics: missing in VHA was In demographics: missing in VHA was replaced by Medicare. When missing from replaced by Medicare. When missing from all sources it was used as a separate all sources it was used as a separate category in regressions.category in regressions.

MeasuresMeasures

Dependent VariablesDependent Variables(FY 2000-2001)(FY 2000-2001)

Mental Illness and Substance Use Disorder (MI/SUD)(MI/SUD) Categories (ICD-9-CM codes)MI:MI: schizophrenia, depressive disorders, bipolar and other psychoses, anxiety and PTSD SUD: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%)

Independent Variables

Statistical ProceduresStatistical Procedures

Chi-square tests Chi-square tests – bivariate associations between MI/SUD bivariate associations between MI/SUD

categories and the independent variables. categories and the independent variables.

Multinomial logistic regressionMultinomial logistic regression– the predictors of the MI/SUD categories. the predictors of the MI/SUD categories. – adjusted odds ratios at 95% CI. adjusted odds ratios at 95% CI. – p-value < 0.01p-value < 0.01

ResultsResults

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

9.8%

2.6%5.3% 6.3%

3.2%

26.7%

Type of MI

Anxiety Disorders Bipolar Disorder DepressionPsychoses PTSD Schizophrenia

Depression was very common

ANY MI = 34%

Tobacco use was very commonTobacco use was very common

18.9%

9.0%

8.0%

Type of MITobacco Alcohol Drug

Any SUD = 26.3%

Mental illness by Mental illness by substances usedsubstances used

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

Anxiety Disorders

Bipolar Disorder

Depression

Psychoses

PTSD

Schizophrenia

Percentage

Tobacco

Drug

Alcohol

MI/SUD CategoriesMI/SUD Categories

MI/SUD categoriesMI/SUD categories were constructed were constructed broadly by combining MI and SUD and broadly by combining MI and SUD and included 4 groups: included 4 groups:

1.1. No MI/SUDNo MI/SUD

2.2. MI onlyMI only

3.3. SUD onlySUD only

4.4. MI/SUD bothMI/SUD both

20%

14%

54%

12%

Over 2 years, 46% had either MI and/or SUD

MI ONLY

SUD ONLY

BOTH

NONE

Rates of mental illness and/or SUD varied by co-morbid conditions

32.3

48.140.3

46.5 47.9 46.0

25.2

28.031.1

25.7 23.8 23.0

15.5

9.410.3 12.0 11.7 13.0

27.014.5 18.3 15.9 16.7 18.0

0%

20%

40%

60%

80%

100%

COPD DM HeartDisease

HTN UTI SkinUlcer

None MI only SUD ony MI/SUD

Multinomial Logistic Regression Comorbidities Comorbidities

MI Only * SUD Only *MI/SUD *

Diabetes

Skin ulcer

Hypertension

COPD

Heart Dis.

UTI

* P <.001

Depression

Adjusted Odds Ratios Multinomial Logistic RegressionAfrican Americans and Latinos

Mi only, 0.71

Mi only, 1.09

SUD only, 0.96SUD only, 0.56

MI/SUD, 0.95

MI/SUD, 0.79

0.30

0.50

0.70

0.90

1.10

1.30

1.50

1 2

Adj

uste

d O

dds

OR

atio

ss

African AmericanLatinoAfrican American Latino

Adjusted Odds RatiosAdjusted Odds RatiosMultinomial Logistic Regression Multinomial Logistic Regression

Duration of SCIDuration of SCI

MI only, 0.51

MI only, 0.69MI only, 0.61

SUD only, 0.78 SUD only, 0.77 SUD only, 0.57

MI/SUD, 0.32

MI/SUD, 0.52MI/SUD, 0.55

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1 2 3

Od

d R

atio

s

10-19 yrs 30 plus yrs20-29 yrs

ConclusionsConclusions

Among veterans with SCI, the prevalence of MI Among veterans with SCI, the prevalence of MI or SUD or both was high (47%) or SUD or both was high (47%) – higher than the 15% in earlier study (Radnitz et al., higher than the 15% in earlier study (Radnitz et al.,

1996). 1996).

Depressive disorders (27%) were comparable to Depressive disorders (27%) were comparable to a recent study of SCI veterans over a three year a recent study of SCI veterans over a three year period (Smith et al., 2007) period (Smith et al., 2007) Our findings revealed that depressive disorders Our findings revealed that depressive disorders were the most common diagnoses. All other were the most common diagnoses. All other diagnoses were present in less than 10% of the diagnoses were present in less than 10% of the population. population.

ConclusionsConclusionsThe association of MI or SUD and physical The association of MI or SUD and physical illnesses in SCI patients was dependent illnesses in SCI patients was dependent on the type of illnesson the type of illness– diabetes were more likely to have depressiondiabetes were more likely to have depression– Skin Ulcer, COPD and hypertension were Skin Ulcer, COPD and hypertension were

strongly associated with MI or SUD in all strongly associated with MI or SUD in all combinationscombinations

– UTI and heart disease were significantly UTI and heart disease were significantly associated with either MI or both MI/SUD. associated with either MI or both MI/SUD.

ConclusionsConclusions

African Americans were less likely to have MI African Americans were less likely to have MI onlyonly

Duration SCI was protective – progressive Duration SCI was protective – progressive decrease in MI and/or SUDdecrease in MI and/or SUD

Paraplegia patients have more SUDParaplegia patients have more SUD

Chronic illness – patterns of MI/SUD were Chronic illness – patterns of MI/SUD were different different

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

LimitationsLimitations

Temporal process of MI can not be testedTemporal process of MI can not be tested– Pre-injury SUD is very highPre-injury SUD is very high

High attrition of study population due to High attrition of study population due to missing on-set datemissing on-set date

MI and SUD may be under-coded MI and SUD may be under-coded – Ours may be considered as a lower-bound Ours may be considered as a lower-bound

estimateestimate

StrengthsStrengthsOur study highlights the complexity of Our study highlights the complexity of illness burden in the SCI veteran illness burden in the SCI veteran population population – Subgroup differences in MI/SUD foundSubgroup differences in MI/SUD foundLarge scale study Large scale study

Differing time periods (immediately after Differing time periods (immediately after injury versus many years later)injury versus many years later)Focus on the gamut of MI and SUDFocus on the gamut of MI and SUD– includes schizophrenia to anxiety disordersincludes schizophrenia to anxiety disorders– includes smokingincludes smoking

Special Thanks toSpecial Thanks to

Patricia Findley, DrPH, MSWPatricia Findley, DrPH, MSW

Bridget Smith, PhDBridget Smith, PhD

Thank youThank youon behalf of a special populationon behalf of a special population