The American Journal on Addictions, 24: 419–426, 2015 Copyright © American Academy of Addiction Psychiatry ISSN: 1055-0496 print / 1521-0391 online DOI: 10.1111/ajad.12219
Correlates of Major Depressive Disorder With and Without Comorbid Alcohol Use Disorder Nationally in the Veterans Health Administration Gihyun Yoon, MD,1,2 Ismene L. Petrakis, MD,1,2 Robert A. Rosenheck, MD1,2 1
VA New England Mental Illness, Research, Education, and Clinical Center, West Haven, Connecticut VA Connecticut Healthcare System, Yale University School of Medicine, West Haven, Connecticut
2
Background and Objectives: This study assesses medical and psychiatric comorbidities, service utilization, and psychotropic medication prescriptions in veterans with comorbid major depressive disorder (MDD) and alcohol use disorder (AUD) relative to veterans with MDD alone. Methods: Using cross-sectional administrative data (fiscal year [FY] 2012: October 1, 2011–September 30, 2012) from the Veterans Health Administration (VHA), we identified veterans with a diagnosis of current (12-month) MDD nationally (N ¼ 309,374), 18.8% of whom were also diagnosed with current (12-month) AUD. Veterans with both MDD and AUD were compared to those with MDD alone on sociodemographic characteristics, current (12-month) medical and psychiatric disorders, service utilization, and psychotropic prescriptions. We then used logistic regression analyses to calculate odds ratio and 95% confidence interval of characteristics that were independently different between the groups. Results: Dually diagnosed veterans with MDD and AUD, relative to veterans with MDD alone, had a greater number of comorbid health conditions, such as liver disease, drug use disorders, and bipolar disorder as well as greater likelihood of homelessness and higher service utilization. Conclusions and Scientific Significance: Dually diagnosed veterans with MDD and AUD had more frequent medical and psychiatric comorbidities and more frequently had been homeless. These data suggest the importance of assessing the presence of comorbid medical/psychiatric disorders and potential homelessness in order to provide appropriately comprehensive treatment to dually diagnosed veterans with MDD and AUD and indicate a need to develop more effective treatments for combined disorders. (Am J Addict 2015;24:419–426)
Received October 15, 2014; revised March 15, 2015; accepted March 21, 2015. Address Correspondence to: Gihyun Yoon, VA Connecticut Healthcare System, 950 Campbell Avenue, 151D, West Haven, CT 06516. E-mail: [email protected]
INTRODUCTION Major depressive disorder (MDD) and alcohol use disorder (AUD) are two of the top five sources of disease burden among all medical diseases in high-income countries as reported by the World Health Organization1 and are relatively common, with lifetime prevalence rates of 13.2 and 30.1%, respectively, in the adult U.S. population.2,3 These two disorders frequently co-occur.4,5 According to the National Longitudinal Alcohol Epidemiologic Survey, 40% of patients with MDD have lifetime comorbid AUD.6 The prevalence rates of MDD and AUD may be even higher in some groups, such as combat veterans.7 In recent years, there has been widespread public concern about depression, suicide, and alcohol abuse among military personnel and veterans. A 2012 report by the Institute of Medicine (IOM) acknowledged the seriousness of alcohol use problems in the U.S. military by noting that binge drinking by active duty service members increased from 35% in 1998 to 47% in 2008.8 Another report by the IOM found that military personnel and veterans commonly have more than one health problem9 and that veterans frequently have co-occurring alcohol problems and depression.10,11 Alcohol problems increase the prevalence of depression.12,13 Also, a diagnosis of depression significantly increases the likelihood of alcohol misuse14 with two studies showing veterans with concurrent depression were 2.1–4.2 times more likely to misuse alcohol.14,15 In addition, suicides, which have been linked to both MDD and AUD, surged to a record high of 349 in 2012 among military personnel.16 Previous studies have suggested that individuals with comorbid MDD and AUD have more severe health conditions than those with MDD alone. In a general population sample, individuals with comorbid depression and AUD had more severe symptoms of depression and more suicidal behaviors than those with MDD alone.17 In addition to these indicators of more severe pathology and symptoms, dual diagnosis of MDD and AUD has also been associated with poorer treatment 419
outcomes,18,19 presumably because each disorder increases the risk and severity of the other in a bidirectional way.20 While some previous studies have thus reported greater problems faced by patients with MDD and AUD, no national study has broadly examined the wide range of differences between dually diagnosed patients with MDD in sociodemographic characteristics, medical comorbidities, psychiatric comorbidities, health service utilization, and psychotropic medication use. For example, one national study examined only psychiatric variables in five groups associated with MDD and AUD,17 but it did not investigate other variables such as medical comorbidities, health service utilization, or psychotropic medication. Understanding these differences in a comprehensive analysis is important in treating this population and designing treatment studies. Further, the effectiveness and side effects of medications may be affected by both psychiatric and medical comorbidities. Since more veterans are presenting to VA facilities for the treatment of this comorbidity,21 it is timely to investigate this comorbidity disorder in greater breadth. The objective of this study was to assess sociodemographic characteristics, medical and psychiatric comorbidities, service utilization, and psychotropic medication prescription fills nationally in VHA patients with comorbid MDD and AUD as compared to those with MDD alone. We hypothesized that veterans with comorbid MDD and AUD, compared to veterans with MDD alone, would have higher rates of medical and psychiatric comorbidities, greater service utilization, and that even after controlling for these differences, would have higher numbers of psychotropic medication prescription fills. To our knowledge, this is the first study to compare these two groups on multiple dimensions using national VHA data.
METHODS Study Sample Using administrative data from the VHA, we identified a total of 3,09,374 veterans who had a diagnosis of MDD (ICD-9 codes 296.2–296.39) nationally in fiscal year (FY) 2012 (October 1, 2011–September 30, 2012). These patients were classified into two groups based on the presence and absence of a diagnosis of AUD (ICD-9 codes 303.xx or 305.00) during the same FY. These national VHA data included all diagnoses coded for all outpatient and inpatient VA services in FY 2012. The VHA data have produced adequate reliability for assessing demographics and selected diagnoses.22 The present study was approved by the Institutional Review Board of the VA Connecticut Healthcare System. A waver of written informed consent was obtained as the study used administrative data with no individual patient identifiers. Measures Sociodemographic measures included gender, age, race, annual income, place of residence, service Operation Enduring 420
Freedom, and Operation Iraqi Freedom (OEF/OIF) veteran status (ie., in the recent wars in Iraq and Afghanistan), homelessness status, VA service connected disability status, and non-service connected pension status. Homelessness status was determined based on having used specialized VA services for homeless veterans or having an ICD-9 diagnosis code for homelessness (V60). Place of residence was classified as urban or rural by using rural-urban commuting area codes.23 OEF/OIF veteran status was assessed using data provided to VHA by the Department of Defense. Using ICD-9 codes in the outpatient encounter file, medical and psychiatric diagnoses were identified. Medical diagnoses included in the Charlson Comorbidity Index24 were diabetes mellitus, cerebrovascular accident, cancer, metastatic cancer, paraplegia, liver disease, headache, connective tissue disease, insomnia, HIV, seizure disorder, peptic ulcer disease, chronic obstructive airway disease, peripheral vascular disease, and myocardial infarction. Pain diagnoses included any pain, herpetic pain, fibromyalgia, musculoskeletal pain, skeletospasm pain, and diabetic pain. Psychiatric diagnoses included MDD, AUD, posttraumatic stress disorder (PTSD), anxiety disorder, bipolar disorder, schizophrenia, dementia, personality disorder, and drug use disorders (cannabis use disorder, cocaine use disorder, opioid use disorder, amphetamine use disorder, hallucinogen use disorder). The Charlson Comorbidity Index is useful for health service research because it assesses general medical comorbidities and predicts mortality by calculating a total weighted score of medical conditions.24 Health service utilization was measured by using bed section discharge codes for any mental health inpatient treatment and for residential rehabilitation and treatment programs. Outpatient clinic stop codes were used to identify use of the following services: the number of mental health outpatient visits, the number of emergency room visits, the number of medical surgical visits, and the number of all outpatient visits. Measures of psychotropic medication prescription fills included the following: receiving any psychotropic medications and the number of any psychotropic prescriptions as well as the number of antidepressant prescriptions, antipsychotic prescriptions, anticonvulsant/mood stabilizer prescriptions, sedative/hypnotic/anxiolytic prescriptions, lithium prescriptions, and stimulant prescriptions. Statistical Analysis Veterans with MDD and AUD versus MDD without AUD were compared using bivariate analyses for sociodemographic characteristics, medical and psychiatric disorders, service utilization, and psychotropic medication prescriptions. We used effect sizes rather than p-values because the large sample size in national data can result in extreme statistical power. Effect sizes were calculated by (i) Cohen’s d (difference in means divided by the pooled standard deviations) for continuous variables and by (ii) risk ratios for dichotomous variables. Effect sizes were considered substantial if (i) Cohen’s d >.5 (moderately large effect size) for continuous
Major Depressive Disorder and Alcohol Use Disorder
August 2015
variables or (ii) risk ratios >2.0 or .5 or (2) Dichotomous variables with risk ratios >2.0 or
Correlates of Major Depressive Disorder With and Without Comorbid Alcohol Use Disorder Nationally in the Veterans Health Administration Gihyun Yoon, MD,1,2 Ismene L. Petrakis, MD,1,2 Robert A. Rosenheck, MD1,2 1
VA New England Mental Illness, Research, Education, and Clinical Center, West Haven, Connecticut VA Connecticut Healthcare System, Yale University School of Medicine, West Haven, Connecticut
2
Background and Objectives: This study assesses medical and psychiatric comorbidities, service utilization, and psychotropic medication prescriptions in veterans with comorbid major depressive disorder (MDD) and alcohol use disorder (AUD) relative to veterans with MDD alone. Methods: Using cross-sectional administrative data (fiscal year [FY] 2012: October 1, 2011–September 30, 2012) from the Veterans Health Administration (VHA), we identified veterans with a diagnosis of current (12-month) MDD nationally (N ¼ 309,374), 18.8% of whom were also diagnosed with current (12-month) AUD. Veterans with both MDD and AUD were compared to those with MDD alone on sociodemographic characteristics, current (12-month) medical and psychiatric disorders, service utilization, and psychotropic prescriptions. We then used logistic regression analyses to calculate odds ratio and 95% confidence interval of characteristics that were independently different between the groups. Results: Dually diagnosed veterans with MDD and AUD, relative to veterans with MDD alone, had a greater number of comorbid health conditions, such as liver disease, drug use disorders, and bipolar disorder as well as greater likelihood of homelessness and higher service utilization. Conclusions and Scientific Significance: Dually diagnosed veterans with MDD and AUD had more frequent medical and psychiatric comorbidities and more frequently had been homeless. These data suggest the importance of assessing the presence of comorbid medical/psychiatric disorders and potential homelessness in order to provide appropriately comprehensive treatment to dually diagnosed veterans with MDD and AUD and indicate a need to develop more effective treatments for combined disorders. (Am J Addict 2015;24:419–426)
Received October 15, 2014; revised March 15, 2015; accepted March 21, 2015. Address Correspondence to: Gihyun Yoon, VA Connecticut Healthcare System, 950 Campbell Avenue, 151D, West Haven, CT 06516. E-mail: [email protected]
INTRODUCTION Major depressive disorder (MDD) and alcohol use disorder (AUD) are two of the top five sources of disease burden among all medical diseases in high-income countries as reported by the World Health Organization1 and are relatively common, with lifetime prevalence rates of 13.2 and 30.1%, respectively, in the adult U.S. population.2,3 These two disorders frequently co-occur.4,5 According to the National Longitudinal Alcohol Epidemiologic Survey, 40% of patients with MDD have lifetime comorbid AUD.6 The prevalence rates of MDD and AUD may be even higher in some groups, such as combat veterans.7 In recent years, there has been widespread public concern about depression, suicide, and alcohol abuse among military personnel and veterans. A 2012 report by the Institute of Medicine (IOM) acknowledged the seriousness of alcohol use problems in the U.S. military by noting that binge drinking by active duty service members increased from 35% in 1998 to 47% in 2008.8 Another report by the IOM found that military personnel and veterans commonly have more than one health problem9 and that veterans frequently have co-occurring alcohol problems and depression.10,11 Alcohol problems increase the prevalence of depression.12,13 Also, a diagnosis of depression significantly increases the likelihood of alcohol misuse14 with two studies showing veterans with concurrent depression were 2.1–4.2 times more likely to misuse alcohol.14,15 In addition, suicides, which have been linked to both MDD and AUD, surged to a record high of 349 in 2012 among military personnel.16 Previous studies have suggested that individuals with comorbid MDD and AUD have more severe health conditions than those with MDD alone. In a general population sample, individuals with comorbid depression and AUD had more severe symptoms of depression and more suicidal behaviors than those with MDD alone.17 In addition to these indicators of more severe pathology and symptoms, dual diagnosis of MDD and AUD has also been associated with poorer treatment 419
outcomes,18,19 presumably because each disorder increases the risk and severity of the other in a bidirectional way.20 While some previous studies have thus reported greater problems faced by patients with MDD and AUD, no national study has broadly examined the wide range of differences between dually diagnosed patients with MDD in sociodemographic characteristics, medical comorbidities, psychiatric comorbidities, health service utilization, and psychotropic medication use. For example, one national study examined only psychiatric variables in five groups associated with MDD and AUD,17 but it did not investigate other variables such as medical comorbidities, health service utilization, or psychotropic medication. Understanding these differences in a comprehensive analysis is important in treating this population and designing treatment studies. Further, the effectiveness and side effects of medications may be affected by both psychiatric and medical comorbidities. Since more veterans are presenting to VA facilities for the treatment of this comorbidity,21 it is timely to investigate this comorbidity disorder in greater breadth. The objective of this study was to assess sociodemographic characteristics, medical and psychiatric comorbidities, service utilization, and psychotropic medication prescription fills nationally in VHA patients with comorbid MDD and AUD as compared to those with MDD alone. We hypothesized that veterans with comorbid MDD and AUD, compared to veterans with MDD alone, would have higher rates of medical and psychiatric comorbidities, greater service utilization, and that even after controlling for these differences, would have higher numbers of psychotropic medication prescription fills. To our knowledge, this is the first study to compare these two groups on multiple dimensions using national VHA data.
METHODS Study Sample Using administrative data from the VHA, we identified a total of 3,09,374 veterans who had a diagnosis of MDD (ICD-9 codes 296.2–296.39) nationally in fiscal year (FY) 2012 (October 1, 2011–September 30, 2012). These patients were classified into two groups based on the presence and absence of a diagnosis of AUD (ICD-9 codes 303.xx or 305.00) during the same FY. These national VHA data included all diagnoses coded for all outpatient and inpatient VA services in FY 2012. The VHA data have produced adequate reliability for assessing demographics and selected diagnoses.22 The present study was approved by the Institutional Review Board of the VA Connecticut Healthcare System. A waver of written informed consent was obtained as the study used administrative data with no individual patient identifiers. Measures Sociodemographic measures included gender, age, race, annual income, place of residence, service Operation Enduring 420
Freedom, and Operation Iraqi Freedom (OEF/OIF) veteran status (ie., in the recent wars in Iraq and Afghanistan), homelessness status, VA service connected disability status, and non-service connected pension status. Homelessness status was determined based on having used specialized VA services for homeless veterans or having an ICD-9 diagnosis code for homelessness (V60). Place of residence was classified as urban or rural by using rural-urban commuting area codes.23 OEF/OIF veteran status was assessed using data provided to VHA by the Department of Defense. Using ICD-9 codes in the outpatient encounter file, medical and psychiatric diagnoses were identified. Medical diagnoses included in the Charlson Comorbidity Index24 were diabetes mellitus, cerebrovascular accident, cancer, metastatic cancer, paraplegia, liver disease, headache, connective tissue disease, insomnia, HIV, seizure disorder, peptic ulcer disease, chronic obstructive airway disease, peripheral vascular disease, and myocardial infarction. Pain diagnoses included any pain, herpetic pain, fibromyalgia, musculoskeletal pain, skeletospasm pain, and diabetic pain. Psychiatric diagnoses included MDD, AUD, posttraumatic stress disorder (PTSD), anxiety disorder, bipolar disorder, schizophrenia, dementia, personality disorder, and drug use disorders (cannabis use disorder, cocaine use disorder, opioid use disorder, amphetamine use disorder, hallucinogen use disorder). The Charlson Comorbidity Index is useful for health service research because it assesses general medical comorbidities and predicts mortality by calculating a total weighted score of medical conditions.24 Health service utilization was measured by using bed section discharge codes for any mental health inpatient treatment and for residential rehabilitation and treatment programs. Outpatient clinic stop codes were used to identify use of the following services: the number of mental health outpatient visits, the number of emergency room visits, the number of medical surgical visits, and the number of all outpatient visits. Measures of psychotropic medication prescription fills included the following: receiving any psychotropic medications and the number of any psychotropic prescriptions as well as the number of antidepressant prescriptions, antipsychotic prescriptions, anticonvulsant/mood stabilizer prescriptions, sedative/hypnotic/anxiolytic prescriptions, lithium prescriptions, and stimulant prescriptions. Statistical Analysis Veterans with MDD and AUD versus MDD without AUD were compared using bivariate analyses for sociodemographic characteristics, medical and psychiatric disorders, service utilization, and psychotropic medication prescriptions. We used effect sizes rather than p-values because the large sample size in national data can result in extreme statistical power. Effect sizes were calculated by (i) Cohen’s d (difference in means divided by the pooled standard deviations) for continuous variables and by (ii) risk ratios for dichotomous variables. Effect sizes were considered substantial if (i) Cohen’s d >.5 (moderately large effect size) for continuous
Major Depressive Disorder and Alcohol Use Disorder
August 2015
variables or (ii) risk ratios >2.0 or .5 or (2) Dichotomous variables with risk ratios >2.0 or
