Publications by authors named "Kara Zivin"

155 Publications

Perinatal insurance coverage and behavioural health-related maternal mortality.

Int Rev Psychiatry 2021 Jun 7:1-4. Epub 2021 Jun 7.

Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.

Increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, are a public health crisis and have contributed to overall increases in maternal mortality. A leading hypothesis to explain this pattern suggests lack of availability or continuity of resources for behavioural health treatment after delivery, often secondary to lapses in insurance coverage. Extending postpartum Medicaid coverage through the first year postpartum could mitigate excess morbidity and mortality among postpartum individuals, particularly those with behavioural health conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/09540261.2021.1903843DOI Listing
June 2021

Employment After Vocational Rehabilitation Predicts Decreased Health Care Utilization in Veterans With Mental Health Diagnoses.

Mil Med 2021 Apr 7. Epub 2021 Apr 7.

Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.

Introduction: Although the benefits of employment for veterans with mental health conditions are well-known, the effect of veterans' employment on a health system has not been evaluated. The purpose of this study was to evaluate the effect of veterans' employment (versus unemployment) on subsequent health care utilization in the Veterans Health Administration (VHA).

Materials And Methods: This study used a sample of 29,022 veterans with mental health and substance use disorders who were discharged from VHA's employment services programs between fiscal years 2006 and 2010. Veterans' employment status (employed/unemployed) upon discharge from VHA employment programs was ascertained from program discharge forms and linked with VHA administrative health care utilization data for the subsequent 1- and 5-year periods.

Results: Multivariable ordinary least-squares and logistic regression models adjusted for site clustering and covariates indicated that employment (versus unemployment) predicted less health care utilization 1 year and 5 years post-discharge from employment services, including fewer outpatient mental health visits, homelessness services visits, employment services visits, primary care visits, and lower odds of mental health hospitalizations, mental health or vocational rehabilitation residential stays, and medical hospitalizations. Employment did not predict emergency department visits.

Conclusions: VHA's investment in employment services for veterans with mental health and substance use disorders could reduce health care utilization system wide.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usab113DOI Listing
April 2021

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

JAMA 2021 03;325(10):952-961

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

Design, Setting, And Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

Exposures: Part D coverage during the observation year (January 1-December 31, 2018).

Main Outcomes And Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

Conclusions And Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2021.1195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944381PMC
March 2021

Healthcare Patterns of Pregnant Women and Children Affected by OUD in 9 State Medicaid Populations.

J Addict Med 2021 Feb 5. Epub 2021 Feb 5.

Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA (MJ, JYK, JMD); Muskie School of Public Service, University of Southern Maine, Portland, ME (KAA); Department of Health Policy, Management, and Leadership, West Virginia University School of Public Health, Morgantown, WV (LA); Department of Maternal and Child Health, University of North Carolina-Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (AA); Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA (AJB); Ohio Colleges of Medicine Government Resource Center, Columbus, OH (DC, RM); School of Social Work, University of North Carolina-Chapel Hill, Chapel Hill, NC (PL); The Hilltop Institute, University of Maryland Baltimore County, Baltimore, MD (SM); Office of Health Affairs, West Virginia University Health Sciences Center, Morgantown, WV (NP); Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY (JT); Departments of Psychiatry and Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI (KZ); Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (KZ).

Objectives: State Medicaid programs are the largest single provider of healthcare for pregnant persons with opioid use disorder (OUD). Our objective was to provide comparable, multistate measures estimating the burden of OUD in pregnancy, medication for OUD (MOUD) in pregnancy, and related neonatal and child outcomes.

Methods: Drawing on the Medicaid Outcomes Distributed Research Network (MODRN), we accessed administrative healthcare data for 1.6 million pregnancies and 1.3 million live births in 9 state Medicaid populations from 2014 to 2017. We analyzed within- and between-state prevalences and time trends in the following outcomes: diagnosis of OUD in pregnancy, initiation, and continuity of MOUD in pregnancy, Neonatal Opioid Withdrawal Syndrome (NOWS), and well-child visit utilization among children with NOWS.

Results: OUD diagnosis increased from 49.6 per 1000 to 54.1 per 1000 pregnancies, and the percentage of those with any MOUD in pregnancy increased from 53.4% to 57.9%, during our study time period. State-specific percentages of 180-day continuity of MOUD ranged from 41.2% to 84.5%. The rate of neonates diagnosed with NOWS increased from 32.7 to 37.0 per 1000 live births. State-specific percentages of children diagnosed with NOWS who had the recommended well-child visits in the first 15 months ranged from 39.3% to 62.5%.

Conclusions: Medicaid data, which allow for longitudinal surveillance of care across different settings, can be used to monitor OUD and related pregnancy and child health outcomes. Findings highlight the need for public health efforts to improve care for pregnant persons and children affected by OUD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ADM.0000000000000780DOI Listing
February 2021

Correction: Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

JMIR Res Protoc 2021 Jan 12;10(1):e26934. Epub 2021 Jan 12.

Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.

[This corrects the article DOI: 10.2196/18345.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/26934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837995PMC
January 2021

Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

JMIR Res Protoc 2020 Dec 21;9(12):e18345. Epub 2020 Dec 21.

Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.

Background: In the Veterans Health Administration (VHA), mental health providers (MHPs) report the second highest level of burnout after primary care physicians. Burnout is defined as increased emotional exhaustion and depersonalization and decreased sense of personal accomplishment at work.

Objective: This study aims to characterize variation in MHP burnout by VHA facility over time, identifying workplace characteristics and practices of high-performing facilities.

Methods: Using both qualitative and quantitative methods, we will evaluate factors that influence MHP burnout and their effects on patient outcomes. We will compile annual survey data on workplace conditions and annual staffing as well as productivity data to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences. We will conduct interviews with mental health leadership at the facility level and with frontline MHPs sampled based on our quantitative findings. We will present our findings to an expert panel of operational partners, Veterans Affairs clinicians, administrators, policy leaders, and experts in burnout. We will reengage with facilities that participated in the earlier qualitative interviews and will hold focus groups that share results based on our quantitative and qualitative work combined with input from our expert panel. We will broadly disseminate these findings to support the development of actionable policies and approaches to addressing MHP burnout.

Results: This study will assist in developing and testing interventions to improve MHP burnout and employee engagement. Our work will contribute to improvements within VHA and will generate insights for health care delivery, informing efforts to address burnout.

Conclusions: This is the first comprehensive, longitudinal, national, mixed methods study that incorporates different types of MHPs. It will engage MHP leadership and frontline providers in understanding facilitators and barriers to effectively address burnout.

International Registered Report Identifier (irrid): PRR1-10.2196/18345.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/18345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781796PMC
December 2020

Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

JMIR Res Protoc 2020 Dec 21;9(12):e18345. Epub 2020 Dec 21.

Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.

Background: In the Veterans Health Administration (VHA), mental health providers (MHPs) report the second highest level of burnout after primary care physicians. Burnout is defined as increased emotional exhaustion and depersonalization and decreased sense of personal accomplishment at work.

Objective: This study aims to characterize variation in MHP burnout by VHA facility over time, identifying workplace characteristics and practices of high-performing facilities.

Methods: Using both qualitative and quantitative methods, we will evaluate factors that influence MHP burnout and their effects on patient outcomes. We will compile annual survey data on workplace conditions and annual staffing as well as productivity data to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences. We will conduct interviews with mental health leadership at the facility level and with frontline MHPs sampled based on our quantitative findings. We will present our findings to an expert panel of operational partners, Veterans Affairs clinicians, administrators, policy leaders, and experts in burnout. We will reengage with facilities that participated in the earlier qualitative interviews and will hold focus groups that share results based on our quantitative and qualitative work combined with input from our expert panel. We will broadly disseminate these findings to support the development of actionable policies and approaches to addressing MHP burnout.

Results: This study will assist in developing and testing interventions to improve MHP burnout and employee engagement. Our work will contribute to improvements within VHA and will generate insights for health care delivery, informing efforts to address burnout.

Conclusions: This is the first comprehensive, longitudinal, national, mixed methods study that incorporates different types of MHPs. It will engage MHP leadership and frontline providers in understanding facilitators and barriers to effectively address burnout.

International Registered Report Identifier (irrid): PRR1-10.2196/18345.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/18345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781796PMC
December 2020

Modeling smoking-attributable mortality among adults with major depression in the United States.

Prev Med 2020 11 27;140:106241. Epub 2020 Aug 27.

Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, United States; Cancer Epidemiology and Prevention Program, University of Michigan Rogel Cancer Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109, United States. Electronic address:

Tobacco-related health disparities disproportionately affect smokers with major depression (MD). Although tobacco simulation models have been applied to general populations, to date they have not considered populations with a comorbid mental health condition. We developed and calibrated a simulation model of smoking and MD comorbidity for the US adult population using the 2005-2018 National Surveys on Drug Use and Health. We use this model to evaluate trends in smoking prevalence, smoking-attributable mortality and life-years lost among adults with MD, and changes in smoking prevalence by mental health status from 2018 to 2060. The model integrates known interaction effects between smoking initiation and cessation, and MD onset and recurrence. We show that from 2018 to 2060, smoking prevalence will continue declining among those with current MD. In the absence of intervention, people with MD will be increasingly disproportionately affected by smoking compared to the general population; our model shows that the smoking prevalence ratio between those with current MD and those without a history of MD increases from 1.54 to 2.42 for men and from 1.81 to 2.73 for women during this time period. From 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with current MD, leading to 11.3 million life-years lost. Ambitious tobacco control efforts could alter this trajectory. With aggressive public health efforts, up to 264,000 of those premature deaths could be avoided, translating into 7.5 million life years gained. This model can compare the relative health gains across different intervention strategies for smokers with MD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ypmed.2020.106241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680404PMC
November 2020

Substance use disorders and risk of severe maternal morbidity in the United States.

Drug Alcohol Depend 2020 11 20;216:108236. Epub 2020 Aug 20.

Magee-Womens Research Institute and Dept of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 3380 Boulevard of the Allies, Pittsburgh, PA 15213, USA; Dept of Epidemiology, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261 USA.

Background: The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

Methods: Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

Results: Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

Conclusion: Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.drugalcdep.2020.108236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606664PMC
November 2020

Changes in Health Care Access and Utilization for Low-SES Adults Aged 51-64 Years After Medicaid Expansion.

J Gerontol B Psychol Sci Soc Sci 2021 Jun;76(6):1218-1230

Department of Internal Medicine, University of Michigan, Ann Arbor.

Objectives: Whether the Affordable Care Act (ACA) insurance expansions improved access to care and health for adults aged 51-64 years has not been closely examined. This study examined longitudinal changes in access, utilization, and health for low-socioeconomic status adults aged 51-64 years before and after the ACA Medicaid expansion.

Methods: Longitudinal difference-in-differences (DID) study before (2010-2014) and after (2016) Medicaid expansion, including N = 2,088 noninstitutionalized low-education adults aged 51-64 years (n = 633 in Medicaid expansion states, n = 1,455 in nonexpansion states) from the nationally representative biennial Health and Retirement Study. Outcomes included coverage (any, Medicaid, and private), access (usual source of care, difficulty finding a physician, foregone care, cost-related medication nonadherence, and out-of-pocket costs), utilization (outpatient visit and hospitalization), and health status.

Results: Low-education adults aged 51-64 years had increased rates of Medicaid coverage (+10.6 percentage points [pp] in expansion states, +3.2 pp in nonexpansion states, DID +7.4 pp, p = .001) and increased likelihood of hospitalizations (+9.2 pp in expansion states, -1.1 pp in nonexpansion states, DID +10.4 pp, p = .003) in Medicaid expansion compared with nonexpansion states after 2014. Those in expansion states also had a smaller increase in limitations in paid work/housework over time, compared to those in nonexpansion states (+3.6 pp in expansion states, +11.0 pp in nonexpansion states, DID -7.5 pp, p = .006). There were no other significant differences in access, utilization, or health trends between expansion and nonexpansion states.

Discussion: After Medicaid expansion, low-education status adults aged 51-64 years were more likely to be hospitalized, suggesting poor baseline access to chronic disease management and pent-up demand for hospital services.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/geronb/gbaa123DOI Listing
June 2021

Perinatal mood and anxiety disorders, serious mental illness, and delivery-related health outcomes, United States, 2006-2015.

BMC Womens Health 2020 07 23;20(1):150. Epub 2020 Jul 23.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Background: National estimates of perinatal mood and anxiety disorders (PMAD) and serious mental illness (SMI) among delivering women over time, as well as associated outcomes and costs, are lacking. The prevalence of perinatal mood and anxiety disorders and serious mental illness from 2006 to 2015 were estimated as well as associated risk of adverse obstetric outcomes, including severe maternal morbidity and mortality (SMMM), and delivery costs.

Methods: The study was a serial, cross-sectional analysis of National Inpatient Sample data. The prevalence of PMAD and SMI was estimated among delivering women as well as obstetric outcomes, healthcare utilization, and delivery costs using adjusted weighted logistic with predictive margins and generalized linear regression models, respectively.

Results: The study included an estimated 39,025,974 delivery hospitalizations from 2006 to 2015 in the U.S. PMAD increased from 18.4 (95% CI 16.4-20.0) to 40.4 (95% CI 39.3-41.6) per 1000 deliveries. SMI also increased among delivering women over time, from 4.2 (95% CI 3.9-4.6) to 8.1 (95% CI 7.9-8.4) per 1000 deliveries. Medicaid covered 72% (95% CI 71.2-72.9) of deliveries complicated by SMI compared to 44% (95% CI 43.1-45.0) and 43.5% (95% CI 42.5-44.5) among PMAD and all other deliveries, respectively. Women with PMAD and SMI experienced higher incidence of SMMM, and increased hospital transfers, lengths of stay, and delivery-related costs compared to other deliveries (P < .001 for all).

Conclusion: Over the past decade, the prevalence of both PMAD and SMI among delivering women increased substantially across the United States, and affected women had more adverse obstetric outcomes and delivery-related costs compared to other deliveries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12905-020-00996-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376899PMC
July 2020

Perinatal mood and anxiety disorders, serious mental illness, and delivery-related health outcomes, United States, 2006-2015.

BMC Womens Health 2020 07 23;20(1):150. Epub 2020 Jul 23.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Background: National estimates of perinatal mood and anxiety disorders (PMAD) and serious mental illness (SMI) among delivering women over time, as well as associated outcomes and costs, are lacking. The prevalence of perinatal mood and anxiety disorders and serious mental illness from 2006 to 2015 were estimated as well as associated risk of adverse obstetric outcomes, including severe maternal morbidity and mortality (SMMM), and delivery costs.

Methods: The study was a serial, cross-sectional analysis of National Inpatient Sample data. The prevalence of PMAD and SMI was estimated among delivering women as well as obstetric outcomes, healthcare utilization, and delivery costs using adjusted weighted logistic with predictive margins and generalized linear regression models, respectively.

Results: The study included an estimated 39,025,974 delivery hospitalizations from 2006 to 2015 in the U.S. PMAD increased from 18.4 (95% CI 16.4-20.0) to 40.4 (95% CI 39.3-41.6) per 1000 deliveries. SMI also increased among delivering women over time, from 4.2 (95% CI 3.9-4.6) to 8.1 (95% CI 7.9-8.4) per 1000 deliveries. Medicaid covered 72% (95% CI 71.2-72.9) of deliveries complicated by SMI compared to 44% (95% CI 43.1-45.0) and 43.5% (95% CI 42.5-44.5) among PMAD and all other deliveries, respectively. Women with PMAD and SMI experienced higher incidence of SMMM, and increased hospital transfers, lengths of stay, and delivery-related costs compared to other deliveries (P < .001 for all).

Conclusion: Over the past decade, the prevalence of both PMAD and SMI among delivering women increased substantially across the United States, and affected women had more adverse obstetric outcomes and delivery-related costs compared to other deliveries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12905-020-00996-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376899PMC
July 2020

U.S. Simulation of Lifetime Major Depressive Episode Prevalence and Recall Error.

Am J Prev Med 2020 08 21;59(2):e39-e47. Epub 2020 May 21.

Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan.

Introduction: Simulation models can improve measurement and understanding of mental health conditions in the population. Major depressive episodes are a common and leading cause of disability but are subject to substantial recall bias in survey assessments. This study illustrates the application of a simulation model to quantify the full burden of major depressive episodes on population health in the U.S.

Methods: A compartmental model of major depressive episodes that explicitly simulates individuals' under-reporting of past episodes was developed and calibrated to 2005-2017 National Surveys on Drug Use and Health data. Parameters for incidence of a first major depressive episode and the probability of under-reporting past episodes were estimated. Analysis was conducted from 2017 to 2019.

Results: The model estimated that 30.1% of women (95% range: 29.0%-32.5%) and 17.4% of men (95% range: 16.7%-18.8%) have lifetime histories of a major depressive episode after adjusting for recall error. Among all adults, 13.1% of women (95% range: 8.1%-16.5%) and 6.6% of men (95% range: 4.0%-8.3%) failed to report a past major depressive episode. Under-reporting of a major depressive episode history in adults aged >65 years was estimated to be 70%.

Conclusions: Simulation models can address knowledge gaps in disease epidemiology and prevention and improve surveillance efforts. This model quantifies the under-reporting of major depressive episodes and provides parameter estimates for future research. After adjusting for under-reporting, 23.9% of adults have a lifetime history of major depressive episodes, which is much higher than based on self-report alone (14.0%). Far more adults would benefit from depression prevention strategies than what survey estimates suggest.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amepre.2020.03.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375917PMC
August 2020

Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy.

Womens Health Issues 2020 Jul - Aug;30(4):292-298. Epub 2020 May 13.

VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.

Background: Researchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans.

Methods: This study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy.

Results: Lifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11-2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19-2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15-2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36-0.96), younger age (OR, 0.95; 95% CI, 0.91-0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37-0.84) were associated with a decreased likelihood of actual VA service use during pregnancy.

Conclusions: Results emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.whi.2020.04.002DOI Listing
August 2020

Relationship Between Faculty Characteristics and Emotional Exhaustion in a Large Academic Medical Center.

J Occup Environ Med 2020 08;62(8):611-617

Department of Psychiatry (Dr Zivin, Dr Brower, Ms Brownlee); Center for Clinical Management Research, Departments of Veterans Affairs and Obstetrics and Gynecology (Dr Zivin); Department of Psychiatry and Molecular and Behavioral Neuroscience Institute (Dr Sen); Departments of Family Medicine and Obstetrics and Gynecology (Dr Gold), University of Michigan Medical School, Ann Arbor, Michigan.

Objective: We evaluated associations between emotional exhaustion (EE), a measure of burnout, among medical school faculty and: demographic and professional characteristics, workplace stressors, coping skills, resilience, sufficient personal time, and depressive symptoms. Respondents completed surveys in November 2017.

Methods: We conducted bivariate and multivariable logistic regression and recycled predictions models to estimate associations between characteristics and probability of EE.

Results: Of 1401 respondents, 42% endorsed EE. Faculty with more clinical effort, more workplace stress, less resilience, less personal time, and more depressive symptoms reported statistically significantly higher probabilities of EE compared with their counterparts. Female sex, mid-career stage, and coping skills were no longer associated with EE, after accounting for stress, resilience, personal time, and depressive symptoms.

Conclusions: Coping skills may not mitigate physician EE when coupled with substantial time and mental health burdens.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JOM.0000000000001898DOI Listing
August 2020

Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States.

Am J Public Health 2020 06 16;110(6):888-896. Epub 2020 Apr 16.

Dara Lee Luca is with Mathematica and Harvard Kennedy School, Cambridge, MA. Caroline Margiotta and Colleen Staatz are with Mathematica, Cambridge. Eleanor Garlow is with Mathematica, Washington, DC, and Emory University, Atlanta, GA. Anna Christensen is with Mathematica, Washington, DC. Kara Zivin is with Mathematica, University of Michigan Medical School, and Department of Veterans Affairs, Ann Arbor.

To estimate the economic burden of untreated perinatal mood and anxiety disorders (PMADs) among 2017 births in the United States. We developed a mathematical model based on a cost-of-illness approach to estimate the impacts of exposure to untreated PMADs on mothers and children. Our model estimated the costs incurred by mothers and their babies born in 2017, projected from conception through the first 5 years of the birth cohort's lives. We determined model inputs from secondary data sources and a literature review. We estimated PMADs to cost $14 billion for the 2017 birth cohort from conception to 5 years postpartum. The average cost per affected mother-child dyad was about $31 800. Mothers incurred 65% of the costs; children incurred 35%. The largest costs were attributable to reduced economic productivity among affected mothers, more preterm births, and increases in other maternal health expenditures. The US economic burden of PMADs is high. Efforts to lower the prevalence of untreated PMADs could lead to substantial economic savings for employers, insurers, the government, and society.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2105/AJPH.2020.305619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204436PMC
June 2020

New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis.

Am J Obstet Gynecol 2020 10 23;223(4):566.e1-566.e13. Epub 2020 Mar 23.

School of Nursing, Women's Studies Department, University of Michigan, Ann Arbor, MI.

Objective: To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery.

Materials And Methods: This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates.

Results: Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99).

Conclusion: Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajog.2020.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508788PMC
October 2020

Racial and Ethnic Disparities in Perinatal Insurance Coverage.

Obstet Gynecol 2020 04;135(4):917-924

Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York; the Departments of Obstetrics and Gynecology and Psychiatry and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; and the Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, the Hennepin Healthcare Research Institute, and the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.

Objective: To measure the association between race-ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points.

Methods: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial-ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race-ethnicity and income.

Results: For each perinatal time point, all categories of racial-ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7-75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2-56.6), 49.9% of indigenous women (95% CI 46.8-53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9-22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women.

Conclusion: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial-ethnic disparities in access to perinatal care and maternal-infant health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000003728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098441PMC
April 2020

Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care.

Psychiatr Serv 2020 03 14;71(3):256-262. Epub 2020 Jan 14.

U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham).

Objective: This study tested whether computerized cognitive-behavioral therapy for depression supported by a peer specialist with lived experience of depression (PS-cCBT) improves mental health-related outcomes for primary care patients.

Methods: In the U.S. Department of Veterans Affairs, primary care patients with a new diagnosis of depression (N=330) were randomly assigned to 3 months of PS-cCBT or a usual-care control condition. Linear mixed-effects models were used to assess differences in depression symptoms, general mental health status, quality of life, and mental health recovery measured at baseline and 3 and 6 months.

Results: In adjusted analyses, participants who received PS-cCBT experienced 1.4 points' (95% confidence interval [CI]=0.3-2.5, p=0.01) greater improvement in depression symptoms on the Quick Inventory of Depression Symptomatology-Self Report at 3 months, compared with the control group, but no significant difference was noted at 6 months. PS-cCBT recipients also had 2.6 points' (95% CI=0.5-4.8, p=0.02) greater improvement in quality of life at 3 months on the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form and greater improvement in recovery on the Recovery Assessment Scale at 3 months (3.6 points; 95% CI=0.9-6.2, p=0.01) and 6 months (4.5 points; 95% CI=1.2-7.7, p=0.01).

Conclusions: PS-cCBT is an effective option for improving short-term depression symptoms and longer-term recovery among primary care patients newly diagnosed as having depression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1176/appi.ps.201900283DOI Listing
March 2020

Perceived sleep quality, coping behavior, and associations with major depression among older adults.

J Health Psychol 2019 Dec 11:1359105319891650. Epub 2019 Dec 11.

University of Michigan, USA.

In older adults, we determined (1) the association of perceived sleep quality with stress-coping behaviors (drinking alcohol, smoking tobacco, medication/drug use, overeating, prayer, exercise, social support, and treatment from a health professional) and (2) whether coping behavior mediated the relationship of perceived sleep quality with depression. Data came from the US Health and Retirement Study 2008-2010 ( = 1174). Using logistic regression, poor perceived sleep quality was associated with medication/drug use (odds ratio = 2.9; 95% confidence interval = 1.4-6.0) and overeating (odds ratio = 1.6; 95% confidence interval = 1.1-2.5). However, using structural equation modeling, coping behavior did not mediate the relationship of perceived sleep quality with depression symptomology ( = 0.14).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1359105319891650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7376440PMC
December 2019

The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model.

Ann Intern Med 2019 12 29;171(11):785-795. Epub 2019 Oct 29.

University of Michigan Medical School, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan School of Public Health, and the Institute for Social Research, University of Michigan, Ann Arbor, Michigan (K.Z.).

Background: Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain.

Objective: To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression.

Design: Decision analytic model.

Data Sources: Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications.

Target Population: Adults with newly diagnosed major depressive disorder in the United States.

Time Horizon: 1 to 5 years.

Perspectives: Health care sector and societal.

Intervention: Initial treatment with either an SGA or group and individual CBT.

Outcome Measures: Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results Of Base-case Analysis: In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, -$1800; societal, -$2500).

Results Of Sensitivity Analysis: In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment.

Limitation: Long-term trials comparing CBT and SGA are lacking.

Conclusion: Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted.

Primary Funding Source: Department of Veterans Affairs, National Institute of Mental Health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7326/M18-1480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7188559PMC
December 2019

Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders.

Psychiatr Serv 2020 01 25;71(1):4-11. Epub 2019 Sep 25.

Institute for Healthcare Policy and Innovation (Tipirneni, Patel, Goold, Kieffer, Ayanian, Clark, Lee, Bryant, Kirch, Solway), School of Public Health (Patel), School of Social Work (Kieffer), Child Health Evaluation and Research Center (Clark), and Institute for Social Research (Lee), all at the University of Michigan, Ann Arbor; Department of Internal Medicine (Tipirneni, Goold, Ayanian, Bryant, Luster), Center for Bioethics and Social Sciences in Medicine (Lewallen), and Department of Psychiatry (Zivin), all at the University of Michigan Medical School, Ann Arbor; Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Zivin).

Objectives: The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).

Methods: Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.

Results: Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.

Conclusions: Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1176/appi.ps.201900179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939140PMC
January 2020

Innovative Solutions for State Medicaid Programs to Leverage Their Data, Build Their Analytic Capacity, and Create Evidence-Based Policy.

EGEMS (Wash DC) 2019 Aug 5;7(1):41. Epub 2019 Aug 5.

University of Pittsburgh Graduate School of Public Health, US.

As states have embraced additional flexibility to change coverage of and payment for Medicaid services, they have also faced heightened expectations for delivering high-value care. Efforts to meet these new expectations have increased the need for rigorous, evidence-based policy, but states may face challenges finding the resources, capacity, and expertise to meet this need. By describing state-university partnerships in more than 20 states, this commentary describes innovative solutions for states that want to leverage their own data, build their analytic capacity, and create evidence-based policy. From an integrated web-based system to improve long-term care to evaluating the impact of permanent supportive housing placements on Medicaid utilization and spending, these state partnerships provide significant support to their state Medicaid programs. In 2017, these partnerships came together to create a distributed research network that supports multi-state analyses. The Medicaid Outcomes Distributed Research Network (MODRN) uses a common data model to examine Medicaid data across states, thereby increasing the analytic rigor of policy evaluations in Medicaid, and contributing to the development of a fully functioning Medicaid innovation laboratory.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5334/egems.311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688544PMC
August 2019

Food Insecurity and Geriatric Hospitalization.

Int J Environ Res Public Health 2019 06 28;16(13). Epub 2019 Jun 28.

Department of Psychiatry, Medical School, University of Michigan, Ann Arbor, MI 48109, USA.

Food insecurity (FI) has been associated with hospitalization, although the pathways underlying this relationship are poorly understood, in part due to the potential for a bidirectional relationship. This study aimed to determine associations of FI with concurrent and future hospitalization among older adults; mediation by depression and; whether hospitalization increased risk of FI. Participants came from the 2012 and 2014 waves of the Health and Retirement Study (HRS; = 13,664). HRS is a prospective cohort representative of U.S. adults over the age of 50. Primary analyses included those who were not hospitalized in 2012 ( = 11,776). Not having enough money to buy necessary food or eating less than desired defined food insecurity. The Composite International Diagnostic Interview Short Form provided depression symptomology. Logistic and linear regression examined concurrent and longitudinal associations of FI in 2012 and 2014 with hospitalization in 2014. Path analysis tested mediation of FI with hospitalization frequency by depression symptomology. Finally, logistic regression examined whether hospitalization in 2012 was longitudinally associated with FI in 2014. FI was not associated with future hospitalization (odds ratio (OR) = 1.1; 95% confidence interval (CI) = 0.9-1.4), however; FI was associated with concurrent hospitalization status (OR = 1.4; 95% CI = 1.1-1.8). Depression symptomology explained 17.4% (95% CI = 2.8-32.0%) the association of FI with concurrent hospitalization frequency. Additionally, hospitalization was associated with becoming food insecure (OR = 1.5; 95% CI = 1.2-2.0). Findings may inform best practices for hospital discharge among older adults.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/ijerph16132294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6651817PMC
June 2019

Predictors of Long-Term and High-Dose Use of Zolpidem in Veterans.

J Clin Psychiatry 2019 02 5;80(2). Epub 2019 Feb 5.

Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.

Objective: Prescriptions for sedative hypnotics are routinely initiated and renewed to treat insomnia, despite evidence supporting nonpharmacologic treatments as comparable and more favorable over time. We used national Veterans Health Administration data to assess patient characteristics associated with high-dose and long-term zolpidem use.

Method: The study included outpatients with new zolpidem prescriptions (January 1, 2013, to June 3, 2014). We defined high-dose use as use of doses above those recommended in the 2013 FDA safety warning (> 5 mg for women, > 10 mg for men) and defined long-term use as at least 180 days of continued supply. We fit separate logistic regression models by sex to evaluate how patient factors, adjusting for facilities, predicted high-dose and long-term use.

Results: Of 139,525 new zolpidem users, < 1% of men and 41% of women used high doses within 180 days of initiation, and 20% continued to use zolpidem long-term. Prior-year use of other sleep medications was associated with both high-dose and long-term use. Substance abuse/dependence was associated with high-dose use in women (odds ratio = 1.20, P < .001). Although long-term use was less likely in those over the age of 85 years, about 1 in 5 users aged 65 to 85 continued long-term. In both sexes, individuals of Hispanic ethnicity and nonwhite races were less likely to use long-term, whereas those with ICD-9-CM-defined psychiatric and sleep disorder diagnoses were more likely to use long-term.

Conclusions: Zolpidem use at a higher-than-recommended dose was common in women who were new zolpidem users. In both sexes, 1 in 5 users continued to use zolpidem for at least 180 days. Efforts to improve access to effective nonpharmacologic treatment alternatives may benefit from attention to subpopulations with higher risk of high-dose and long-term use.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4088/JCP.18m12149DOI Listing
February 2019

Individual and neighborhood characteristics as predictors of depression symptom response.

Health Serv Res 2019 06 4;54(3):586-591. Epub 2019 Mar 4.

Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan.

Objective: Assess whether neighborhood characteristics predict patient-reported outcomes for depression.

Data Sources: VA electronic medical record data and U.S. census data.

Study Design: Retrospective longitudinal cohort.

Data Extraction Methods: Neighborhood and individual characteristics of patients (N = 4,269) with a unipolar depressive disorder diagnosis and an initial Patient Health Questionnaire (PHQ-9) score ≥10 were used to predict 50 percent improvement in 4-8-month PHQ-9 scores.

Principal Findings: The proportion of a patient's neighborhood living in poverty (OR = 0.98; 95% CI: 0.97-.1.00; P = 0.03) was associated with lower likelihood of depression symptom improvement in addition to whether the patient was black (OR = 0.76; 95% CI:0.61-0.96; P = 0.02) had PTSD (OR = 0.59; 95% CI:0.50-0.69; P < 0.001) or had any service-connected disability (OR = 0.73; 95% CI:0.61-0.87; P < 0.001).

Conclusions: Neighborhood poverty should be considered along with patient characteristics when determining likelihood of depression improvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/1475-6773.13127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6505422PMC
June 2019

Depression, food insecurity and diabetic morbidity: Evidence from the Health and Retirement Study.

J Psychosom Res 2019 02 19;117:22-29. Epub 2018 Dec 19.

Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, United States.

Objective: This study examined whether diabetic morbidity mediates the relationship of food insecurity with depression among older adults with diabetes.

Methods: Data came from the 2010-2014 waves of the Health and Retirement Study and analyses were limited to respondents with diabetes (n = 2951). Depression was indexed by the 8-item Centers for Epidemiologic Studies Depression Scale. Weighted logistic regression was used to examine relationships of food insecurity and diabetic morbidity with depressive symptoms, both cross-sectionally and longitudinally. Path analysis quantified the contribution of diabetic morbidity as a mediation of the relationship of food insecurity with depressive symptoms.

Results: Food insecurity was associated with having poor diabetes control (odds ratio (OR) = 1.7; 95% confidence interval (CI) = 1.1-2.5) and diabetes-related kidney problems (OR = 1.6; 95% CI = 1.1-2.5). Additionally, food insecurity was associated with depression contemporaneously (OR = 2.0, 95% CI = 1.7-2.4) and longitudinally (OR = 1.5, 95% CI = 1.3-1.8). However, food insecurity was no longer associated with depression when adjusting for diabetic morbidity. In path analyses, diabetic morbidity explained 12.7% (p-value = .04) of the association of food insecurity with depressive symptoms in 2012 and 18.5% (p-value = .09) of the association with depressive symptoms in 2014.

Conclusion: The relationship of food insecurity with depression was attributable to worse diabetes morbidity. Interventions that reduce food insecurity among older adults with diabetes may improve disease management and reduce depression severity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpsychores.2018.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467465PMC
February 2019

Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015.

Obstet Gynecol 2018 11;132(5):1158-1166

Departments of Obstetrics and Gynecology and Psychiatry, the Institute for Healthcare Policy and Innovation, and the Program on Women's Healthcare Effectiveness Research, University of Michigan, Ann Arbor, Michigan; the VA Ann Arbor Healthcare System, Ann Arbor, Michigan; the Departments of Internal Medicine and Pediatrics, Hennepin Healthcare, and Hennepin Healthcare Research Institute, Minneapolis, Minnesota; the Departments of Obstetrics and Gynecology and Psychiatry, Virginia Commonwealth University, Richmond, Virginia; and the Department of Anesthesiology, University of Arkansas, Little Rock, Arkansas.

Objective: To describe racial and ethnic disparities in the incidence of severe maternal morbidity during delivery hospitalizations in the United States.

Methods: We conducted a pooled, cross-sectional analysis of 2012-2015 data from the National Inpatient Sample to define the prevalence of chronic conditions and incidence of severe maternal morbidity among deliveries to non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander, and Native American or Alaska Native women. We used weighted multivariable logistic regression and predictive margins to generate prevalence and incidence estimates. Adjusted rate ratios and differences were calculated to quantify disparities across racial and ethnic categories. Subgroup analyses were performed to examine the incidence of severe maternal morbidity among deliveries to women with comorbid physical health conditions, behavioral health conditions, and multiple chronic conditions within each racial and ethnic category.

Results: The incidence of severe maternal morbidity was significantly higher among deliveries to women in every racial and ethnic minority category compared with deliveries among non-Hispanic white women. Severe maternal morbidity occurred in 231.1 (95% CI 223.6-238.5) and 139.2 (95% CI 136.4-142.0) per 10,000 delivery hospitalizations among non-Hispanic black and non-Hispanic white women, respectively (P<.001). When excluding cases in which blood transfusion was the only indicator of severe maternal morbidity, only deliveries to non-Hispanic black women had a higher incidence of severe maternal morbidity compared with deliveries among non-Hispanic white women: 50.2 (95% CI 47.6-52.9) and 40.9 (95% CI 39.6-42.3) per 10,000 delivery hospitalizations, respectively (risk ratio 1.2 [95% CI 1.2-1.3], risk difference 9.3 [95% CI 6.5-12.2] per 10,000 delivery hospitalizations; P<.001 for each comparison). Among deliveries to women with comorbid physical and behavioral health conditions, significant differences in severe maternal morbidity were identified among racial and ethnic minority compared with non-Hispanic white women and the largest disparities were identified among women with multiple chronic conditions.

Conclusion: Programs for reducing racial and ethnic disparities in severe maternal morbidity may have the greatest effect focusing on women at highest risk for blood transfusion and maternity care management for women with comorbid chronic conditions, particularly multiple chronic conditions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/AOG.0000000000002937DOI Listing
November 2018