Thesis Defense [06102010]

Mental health status, and the use of mental health services

and psychotherapeutic medicines among U.S. cancer survivors and their spouses

A Dissertation inHealth Policy and Administration

AndDemography

byRajeshwari S. Punekar

Overview Background Objectives Contributions Conceptual Framework Literature Review Methods

Data Measures Analysis

Results Policy Implications Limitations

Background Increase in number of cancer survivors Development of a cancer survivor advocacy

community Emphasis on understanding the Quality of Life

(QOL) of cancer survivors and their family members Current literature lacks information on the mental

health status and the utilization of mental health services and prescribed psychotherapeutic medications for the whole U.S. oncology population§.

§ Oncology Population refers to U.S. cancer survivors and their spouses

Objectives To describe mental health status, mental health service

utilization, and psychotherapeutic medicine utilization among U.S. cancer survivors and their spouses.

To compare mental health status, mental health service utilization, and psychotherapeutic medicine utilization between the oncology population and the general population.

To identify the predictors of mental health status, mental health service utilization, and psychotherapeutic medicine utilization within the oncology population.

Contributions First study to produce the national estimates of

mental health status, psychological distress, depression, and psychotherapeutic medicines utilization for U.S. cancer survivors and their spouses

First study to compare psychotherapeutic medicines utilization between the oncology population and the general population

First study to explore psychotherapeutic medicines utilization patterns among cancer survivors’ spouses

Conceptual Framework

General Health

Socio-economic• Education• Employment• Income

Demographic• Age• Gender• Race• Marital status

Mental Health Status

Resources• Socio-emotional support• Communication within a family

Diagnosis or history of cancerCancer characteristics

– Cancer site– Stage of cancer– Recurrence – Age at diagnosis– Time since diagnosis– Type of treatment

Use of Mental Health Services and

Psychotherapeutic Medicines

Mental Health Status Mixed results regarding the mental health status of cancer survivors.

Bradley, Rose, Lutgendorf, Costanzo, & Anderson, 2006; and Ferrario, Zotti, Massara, & Nuvolone, 2003 report that both short-term and long term cancer survivors have higher anxiety and depression levels than the general population.

Keating, Nørredam, Landrum, Huskamp, & Meara, 2005; Mols et al., 2006; Bardwell et al., 2004; and Parker, Baile, Moor, & Cohen, 2003 report that cancer survivors have similar or better mental health status than the general population.

Ferrario, Zotti, Massara, & Nuvolone, 2003; Wagner, Bigatti, & Storniolo, 2006; Cochrane, Goering, & Rogers, 1997; Pruchno & Potashnik, 1989 show that the spouses of cancer survivors more depressed and have more psychological distress and anxiety compared to the spouses of non-cancer adults

Mental Health Services Utilization Hewitt & Rowland, 2002 and Earle, Neville, &

Fletcher, 2007 show that cancer survivors use more mental health services compared to the general population.

Investigations into the mental health service utilization among spouses of cancer survivors are very rare.

Psychotherapeutic Medicines Utilization Derogatis et al., 1979; Goldberg & Mor, 1985; Stiefel,

Kornblith, & Holland, 1990; and Cullivan, Crown, & Walsh, 1998 Examined the prescription patterns of psychotropic

medicines among hospitalized cancer patients Compared it with the prescription rates of psychotropic

medicines in the general population, which were derived from other research studies.

Concluded that cancer survivors use more psychotropic medicines compared to the general population.

Investigations into the utilization of psychotropic medicines among spouses of cancer survivors are almost non-existent.

Medical Expenditure Panel Survey- Household Component (MEPS-HC) A nationally representative household survey with an

overlapping panel design. The household component of the MEPS (MEPS-HC) is drawn

from the previous year's NHIS sample. Individuals with a history or diagnosis of cancer are identified

through cancer-related health care utilization events, which are identified with the help of the clinical classification condition codes.

Information about demographics, socio-economic characteristics, health status, and health care utilization.

National Health Interview Survey (NHIS) A cross-sectional multistage household interview

survey. The study sample restricted to the sample adult

population. Individuals with a history or diagnosis of cancer are

identified by asking individuals, “Has a doctor or other health providers told you that you have a cancer or malignancy of any kind?”

Information about cancer sites, age when diagnosed with cancer, and time since diagnosed with cancer.

Data

1999-2005NHIS

Cancer cases- 1,957 Spouses- 826

2001-2006MEPS-HC

Cancer cases- 679 Spouses- 300

2001-2006 NHIS-MEPS link files

Measures Mental health status

Mental component scores (MCS-12) of the SF-12 Psychological Distress

Kessler Index (K6) Depression

Patient Health Questionnaire-2 Mental health service utilization

Total annual number of events for mental health disorders Psychotropic medicine utilization

Total annual number of psychotropic medicine prescriptions.

Analysis

MEPS Person-level Survey Weights Weight Adjustment

Adjustment factor1f = Σi weight if / weight 1f

Post Stratification Raking

Rescaling weights Survey Design Adjustment

Taylor-series Linearization

Descriptive Analysis

Outcomes 25-64 65 and older

Cancer Non-cancer Cancer Non-cancer

Mental Component Scores of SF-12 a

49 51 52 52

Non-Specific Psychological Distress (K6) Scores a

6 4 4 5

% % % %

Depression a 10 5 9 7

Mental Health Services Use a 16 11 10 10

Psychotherapeutic Medicines Use a,b

17 10 15 12

Individuals

a Cancer and non-cancer individuals, below ages of 65 years, are significantly different at p=0.05 levelb Cancer and non-cancer individuals, 65 and older, are significantly different at p=0.05 level

Descriptive Analysis

Outcomes 25-64 65 and older

Cancer Non-cancer Cancer Non-cancer

Mental Component Scores of SF-12 a

50 52 53 53

Non-Specific Psychological Distress (K6) Scores a

4 3 3 3

% % % %

Depression a,b 7 4 10 6

Mental Health Services Use 12 9 10 7

Psychotherapeutic Medicines Use a,b

27 16 23 18

Spouses

a Cancer and non-cancer individuals, below ages of 65 years, are significantly different at p=0.05 levelb Cancer and non-cancer individuals, 65 and older, are significantly different at p=0.05 level

Multivariate AnalysisDependent variables: Mental health status Psychological distress Depression Mental health services use Psychotherapeutic medications

use

Independent variables: Cancer diagnosis Cancer sites Time since diagnosed with cancer Age Gender Race Ethnicity Marital Status Education Chronic conditions

Regression coefficients and Odds Ratios (OR) for the outcome of interests in full sample

Outcomes Individuals Spouses

25-64 65 and older

25-64 65 and older

MCS-12 -1.15* -0.42 -1.12* -0.31

Psychological distress 0.23* 0.15* 0.23* 0.09

Depression (OR) 1.59* 1.42* 1.77* 1.88*

Mental health services utilization (OR)

1.16 1.04 1.01 1.27

Psychotherapeutic medicines utilization (OR)

1.33* 1.23* 1.34* 1.31*

* Significant at p=0.05 level

Regression coefficients for the outcomes of interests in the oncology sample

Individuals Spouses

25-64 65 and older

25-64 65 and older

MCS-12

Colorectal cancer -0.41 0.22 -0.15 -0.12

Gynecological cancer -2.33* -2.25 -1.10 -3.01

Lung cancer 0.92 0.03 2.96 0.26

Prostate cancer 1.51 -1.28 1.07 -1.66

Psychological Distress

Colorectal cancer -0.16 -0.58* -0.69 -0.68

Gynecological cancer 0.45* 0.37 0.32 0.56

Lung cancer -0.48 0.46 -1.29 0.51

Prostate cancer -0.25 0.24 -0.52 0.41

•Significant at p=0.05 level

•Reference group: Breast Cancer Survivors

Odds Ratios (OR) for the outcomes of interests in the oncology sample

1.070.310.840.55Prostate cancer

0.540.420.670.95Lung cancer

0.431.260.921.11Gynecological cancer

0.821.860.861.03Colorectal cancer

Psychotherapeutic medicines utilization

2.470.79*2.42*0.73Prostate cancer

0.270.89*0.620.82Lung cancer


0.304.73*0.811.07Colorectal cancer

Mental Health Services utilization


0.920.830.610.89Lung cancer

0.592.190.672.71*Gynecological cancer


Depression

65 and older25-6465 and older25-64

SpousesIndividualsPredictors


0.540.420.670.95Lung cancer



Psychotherapeutic medicines utilization

2.470.79*2.42*0.73Prostate cancer

0.270.89*0.620.82Lung cancer


0.304.73*0.811.07Colorectal cancer

Mental Health Services utilization


0.920.830.610.89Lung cancer

0.592.190.672.71*Gynecological cancer


Depression

65 and older25-6465 and older25-64

SpousesIndividualsPredictors

* Significant at p=0.05 level

Summary Cancer survivors and their spouses have lower mental

health status and higher psychological distress than the general population.

Cancer survivors and their spouses are more likely to be depressed than the general population.

Cancer survivors and their spouses are equally likely to use mental health services compared to the general population.

Cancer survivors and their spouses are more likely to use psychotherapeutic medicines than the general population.

Policy Implications Policymakers and clinicians should focus on the

mental health problems of cancer survivors as well as their spouses

Oncologists and primary care physicians should screen gynecological cancer survivors between 25 and 64 years of age for mental health problems and refer them to mental health professionals.

Insurance companies should offer generous coverage on prescription psychotropic medicines for cancer survivors and their spouses.

Limitations Lacks information about the stage of cancer and the

type of treatment No adequate sample sizes for less prevalent cancer

sites such as brain and bone cancers Utilization is self-reported, not based on medical

records or insurance claims

Thesis Defense [06102010]

Health & Medicine

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