Alcohol, tobacco, drug use far higher in severely mentally ill

In the largest ever assessment of substance use among people with severe psychiatric illness, researchers at Washington University School of Medicine in St. Louis and the University of Southern California have found that rates of smoking, drinking and drug use are significantly higher among those who have psychotic disorders than among those in the general population. The study is published online in the journal JAMA Psychiatry. The finding is of particular concern because individuals with severe mental illness are more likely to die younger than people without severe psychiatric disorders. "These patients tend to pass away much younger, with estimates ranging from 12 to 25 years earlier than individuals in the general population," said first author Sarah M. Hartz, MD, PhD, assistant professor of psychiatry at Washington University. "They don't die from drug overdoses or commit suicide — the kinds of things you might suspect in severe psychiatric illness. They die from heart disease and cancer, problems caused by chronic alcohol and tobacco use." The study analyzed smoking, drinking and drug use in nearly 20,000 people. That included 9,142 psychiatric patients diagnosed with schizophrenia, bipolar disorder or schizoaffective disorder — an illness characterized by psychotic symptoms such as hallucinations and delusions, and mood disorders such as depression. The investigators also assessed nicotine use, heavy drinking, heavy marijuana use and recreational drug use in more than 10,000 healthy people without mental illness. The researchers found that 30 percent of those with severe psychiatric illness engaged in binge drinking, defined as drinking four servings of alcohol at one time. In comparison, the rate of binge drinking in the general population is 8 percent. Among those with mental illness, more than 75 percent were regular smokers. This compares with 33 percent of those in the control group who smoked regularly. There were similar findings with heavy marijuana use: 50 percent of people with psychotic disorders used marijuana regularly, versus 18 percent in the general population. Half of those with mental illness also used other illicit drugs, while the rate of recreational drug use in the general population is 12 percent. "I take care of a lot of patients with severe mental illness, many of whom are sick enough that they are on disability," said Hartz. "And it's always surprising when I encounter a patient who doesn't smoke or hasn't used drugs or had alcohol problems." Hartz said another striking finding from the study is that once a person develops a psychotic illness, protective factors such as race and gender don't have their typical influence. Previous research indicates that Hispanics and Asians tend to have lower rates of substance abuse than European Americans. The same is true for women, who tend to smoke, drink and use illicit drugs less often than men. "We see protective effects in these subpopulations," Hartz explained. "But once a person has a severe mental illness, that seems to trump everything." That's particularly true, she said, with smoking. During the last few decades, smoking rates have declined in the general population. People over age 50 are much more likely than younger people to have been regular smokers at some point in their lives. For example, about 40 percent of those over 50 used to smoke regularly. Among those under 30, fewer than 20 percent have been regular smokers. But among the mentally ill, the smoking rate is more than 75 percent, regardless of the patient's age. "With public health efforts, we've effectively cut smoking rates in half in healthy people, but in the severely mentally ill, we haven't made a dent at all," she said. Until recently, smoking was permitted in most psychiatric hospitals and mental wards. Hartz believes that many psychiatrists decided that their sickest patients had enough problems without having to worry about quitting smoking, too. There also were concerns about potential dangers from using nicotine-replacement therapy, while continuing to smoke since smoking is so prevalent among the mentally ill. Recent studies, however, have found those concerns were overblown. The question, she said, is whether being more aggressive in trying to curb nicotine, alcohol and substance use in patients with severe psychiatric illness can lengthen their lives. Hartz believes health professionals who treat the mentally ill need to do a better job of trying to get them to stop smoking, drinking and using drugs. "Some studies have shown that although we psychiatrists know that smoking, drinking and substance use are major problems among the mentally ill, we often don't ask our patients about those things," she said. "We can do better, but we also need to develop new strategies because many interventions to reduce smoking, drinking and drug use that have worked in other patient populations don't seem to be very effective in these psychiatric patients." CADC I & II Continuing Education ### Funding for this research comes from the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH) and the National Cancer Institute (NCI) of the National Institutes of Health (NIH), and the American Cancer Society. NIH grant numbers R01 DA032843, R01 DA025888, U10 AA008401, UL1 RR024992, P01 CA089392, R01 MH085548, R01 MH085542, K08 DA032680-1, Kl2 RR024994, K01 DA025733. Hartz SM, Pato CN, Medeiros H, Cavazos-Rehg P, Sobell JL, Knowles JA, Bierut LJ, Pato MT and the Genomic Psychiatry Cohort Consortium. JAMA Psychiatry Published online Jan. 1, 2014. doi:10.1001/jamapsychiatry.2013.3276 Washington University School of Medicine's 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked sixth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

Medicare beneficiaries overspend by hundreds, Pitt Public Health finds

PITTSBURGH, Oct. 9, 2012 – Medicare beneficiaries are overpaying by hundreds of dollars annually because of difficulties selecting the ideal prescription drug plan for their medical needs, an investigation by University of Pittsburgh Graduate School of Public Health researchers reveals. Only 5.2 percent of beneficiaries chose the least-expensive Medicare prescription drug benefit (Part D) plan that satisfied their medical needs in 2009, overspending on Part D premiums and prescription drugs by an average of $368 a year. The evaluation, published in the October issue of the journal Health Affairs, takes a national look at how well beneficiaries were making plan choices in the fourth year of the Medicare Part D program and could help guide changes to health insurance programs. "People need assistance in choosing the least expensive plan for their medical needs," said lead author Chao Zhou, Ph.D., a post-doctoral associate at Pitt Public Health. "Educational programs that help people navigate the dozens of plans available would make it easier to select plans that best meet their health care needs without overspending." "In particular, government officials could recommend the three most appropriate Part D plans for each person, based on their medication history," said co-author Yuting Zhang, Ph.D., associate professor of health economics at Pitt Public Health. "Alternatively, they could assign beneficiaries to the best plan for them based on their medication needs, while offering them the option to choose another plan instead." The results of this study could be useful in designing health insurance exchanges, which are state-regulated organizations created under health care reform to offer standardized health care plans. "In designing health insurance exchanges, models with more active assistance would be more helpful than models with large numbers of plans and information," Dr. Zhang said. "For example, health insurance exchanges could actively screen plans on quality and negotiate premiums to reduce the number of plans." Implemented in 2006, Part D cost the federal government $65.8 billion in 2011, according to the Congressional Budget Office. The researchers looked at the difference in a patient's total spending, including the plan premium and out-of-pocket payment for the prescriptions filled, between the plan the patient chose and the cheapest alternative option in the region that would satisfy the patient's medication needs. The study looked at data for 412,712 people, with an average age of 75. Beneficiaries tend to overprotect themselves by purchasing plans with more generous features, such as generic drug coverage in the coverage gap. A few other trends emerged: As beneficiaries aged, they increasingly chose more expensive plans, with people older than 85 overspending by $30 more than people 65 to 69 years old. Blacks, Hispanics and Native Americans chose less expensive plans than whites. People with common medical conditions, such as diabetes and chronic heart failure, were not significantly more likely to choose more expensive plans. People with cognitive deficits or mental health issues, such as Alzheimer's disease, tended to choose less expensive plans, spending an average of $10 less than those without such conditions. The researchers could not determine if those people had assistance from caregivers. As the number of plan options increased in a region, the amount of overspending increased by $3.20 for every additional plan available. "A previous study showed that in 2006, beneficiaries could have saved nearly 31 percent of their total drug spending by switching to the lowest cost plan," Dr. Zhou said. "Since our results are similar, this suggests people are not learning to reduce overspending." One possible explanation for these consistent results over time is the impact of inertia and bias toward maintaining the status quo, she noted. "When Medicare Part D started in 2006, the majority of beneficiaries did not choose the least expensive plan," Dr. Zhou said. "Over time, they may have simply stuck to their original plan and never switched to a better one. Beneficiaries might not spend much time researching and adjusting their plan choices based on changes in their medication needs and in plan options." Findings from the private health insurance market support the authors' conclusion that people keep their current plan instead of spending time researching and optimizing their plan choices based on their insurance use and prescription spending in the previous year CADC I & II Continuing Education ### About the University of Pittsburgh Graduate School of Public Health The University of Pittsburgh Graduate School of Public Health, founded in 1948 and now one of the top-ranked schools of public health in the United States, conducts research on public health and medical care that improves the lives of millions of people around the world. Pitt Public Health is a leader in devising new methods to prevent and treat cardiovascular diseases, HIV/AIDS, cancer and other important public health problems. For more information about Pitt Public Health, visit the school's Web site at www.publichealth.pitt.edu. http://www.upmc.com/media

The effects of discrimination could last a lifetime

Increased levels of depression as a result of discrimination could contribute to low birth weight babies Given the well-documented relationship between low birth weight and the increased risk of health problems throughout one’s lifespan, it is vital to reduce any potential contributors to low birth weight. A new study by Valerie Earnshaw and her colleagues from Yale University sheds light on one possible causal factor. Their findings, published online in Springer's journal, the Annals of Behavioral Medicine, suggest that chronic, everyday instances of discrimination against pregnant, urban women of color may play a significant role in contributing to low birth weight babies. Twice as many black women give birth to low birth weight babies than white or Latina women in the U.S. Reasons for this disparity are, as yet, unclear. But initial evidence suggests a link may exist between discrimination experienced while pregnant and the incidence of low birth weight. In addition, experiences of discrimination have also been linked to depression, which causes physiological changes that can have a negative effect on a pregnancy CADCA Continuing Education Earnshaw and her colleagues interviewed 420, 14- to 21-year-old black and Latina women at 14 community health centers and hospitals in New York, during the second and third trimesters of their pregnancies, and at six and 12 months after their babies had been born. They measured their reported experiences of discrimination. They also measured their depressive symptoms, pregnancy distress and pregnancy symptoms. Levels of everyday discrimination reported were generally low. However, the impact of discrimination was the same in all the participants regardless of age, ethnicity or type of discrimination reported. Women reporting greater levels of discrimination were more prone to depressive symptoms, and ultimately went on to have babies with lower birth weights than those reporting lower levels of discrimination. This has implications for healthcare providers who work with pregnant teens and young women during the pre-natal period, while they have the opportunity to try and reduce the potential impacts discrimination on the pregnancy. The authors conclude that "Given the associations between birth weight and health across the life span, it is critical to reduce discrimination directed at urban youth of color so that all children are able to begin life with greater promise for health. In doing so, we have the possibility to eliminate disparities not only in birth weight, but in health outcomes across the lifespan." Data for this study came from the Centering Pregnancy Plus project, funded by the National Institute of Mental Health, and conducted in collaboration with Clinical Directors’ Network and the Centering Healthcare Institute. References 1. Earnshaw VA, Rosenthal L, Lewis JB, Stasko EC, Tobin JN, Lewis TT, Reid AE and Ickovics JR (2012). Maternal experiences with everyday discrimination and infant birth weight: a test of the mediators and moderators among young, urban women of color. Annals of Behavioral Medicine; DOI 10.1007/s12160-012-9404-3