Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis

Background 

There is a higher mortality rate due to cancer in people with mental illness and previous work suggests suboptimal medical care in this population. It remains unclear if this extends to breast cancer population screening.

Aims 

To conduct a systematic review and meta-analysis to establish if women with a mental health condition are less likely to receive mammography screening compared with those without mental ill health.

Method 

Major electronic databases were searched from inception until February 2014. We calculated odds ratios (OR) with a random effects meta-analysis comparing mammography screening rates among women with and without a mental illness. Results were stratified according to primary diagnosis including any mental illness, mood disorders, depression, severe mental illness (SMI), distress and anxiety.

Results 

We identified 24 publications reporting breast cancer screening practices in women with mental illness ( n = 715 705). An additional 5 studies investigating screening for those with distress ( n = 21 491) but no diagnosis of mental disorder were identified. The pooled meta-analysis showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66-0.77), mood disorders (OR = 0.83, 95% CI 0.76-0.90) and particularly SMI (OR = 0.54, 95% CI 0.45-0.65). No disparity was evident among women with distress alone.

Conclusions 

Rates of mammography screening are lower in women with mental illness, particularly women with SMI, and this is not explained by the presence of emotional distress. Disparities in medical care due to mental illness clearly extend into preventive population screening.

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Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

Objectives To study the duration of depression, recovery over time, and predictors of prognosis in an older cohort (≥55 years) in primary care.

Design Longitudinal cohort study, with three years’ follow-up.

Setting 32 general practices in West Friesland, the Netherlands.

Participants 234 patients aged 55 years or more with a prevalent major depressive disorder.

Main outcome measures Depression at baseline and every six months using structured diagnostic interviews (primary care evaluation of mental disorders according to diagnoses in Diagnostic and Statistical Manual of Mental Disorders, fourth edition) and a measure of severity of symptoms (Montgomery Asberg depression rating scale). The main outcome measures were time to recovery and the likelihood of recovery at different time points. Multivariable analyses were used to identify variables predicting prognosis.

Results The median duration of a major depressive episode was 18.0 months (95% confidence interval 12.8 to 23.1). 35% of depressed patients recovered within one year, 60% within two years, and 68% within three years. A poor outcome was associated with severity of depression at baseline, a family history of depression, and poorer physical functioning. During follow-up functional status remained limited in patients with chronic depression but not in those who had recovered.

Conclusion Depression among patients aged 55 years or more in primary care has a poor prognosis. Using readily available prognostic factors (for example, severity of the index episode, a family history of depression, and functional decline) could help direct treatment to those at highest risk of a poor prognosis.

https://www.bmj.com/content/bmj/338/bmj.a3079.full.pdf

Outcome of depression in later life in primary care: longitudinal cohort study with three years’ follow-up

Objective: The objective of the study is to systematically analyze and summarize research literature regarding health serviceuse and costs of depressive symptoms in late life. Design: Relevant articles were identified by systematically searching the databasesMEDLINE, Web of Science, PSYNDEXplus, PsycINFO, and Cochrane Library. Keywords were ‘depression’ or ‘depressive*’, and‘cost’ or ‘economic burden’ or ‘utilization’ or ‘use’ and ‘old age’ or ‘elderly’. Studies based on representative samples of elderly individualsaged 55 years and older were included. Results: 55 studies were found, 34 studies determined health service utilization, 10 studiesreported costs, and 11 studies reported both. Studies of health service utilization and costs showed homogeneously that depressive elderlyindividuals have an increased service use compared to non-depressive, and a one-third increase of outpatient, inpatient, and totalhealthcare costs of depressive individuals. The majority of studies reported antidepressant (AD) use between 20 and 45% by depressiveindividuals. Mean annual costs for AD ranged from 108 to 305 US$ PPP (purchasing power parities). Increased service use and costs areonly to a small proportion related to depression treatment. Conclusions: Depressive symptoms in late life lead to a high economic burdenfor nations which is not explained by costs for depressive symptom treatment. Strategies for improvement of diagnostic validity andtreatment success of depressive symptoms in late life may have an effect on economic burden for societies.

Health Service Utilization and Costs of Depressive Symptoms in Late Life - A Systematic Review

Studies on the association between access to health care and household income have rarely included an assessment of 'forgone care', but this indicator could add to our understanding of the inverse care law. We hypothesize that reporting forgone care is more prevalent in low income groups. The study is based on the 'Survey of Health, Ageing and Retirement in Europe (SHARE)', focusing on the non-institutionalized population aged 50 years or older. Data are included from France, Germany, Greece, Italy and Sweden. The dependent variable is assessed by the following question: During the last twelve months, did you forgo any types of care because of the costs you would have to pay, or because this care was not available or not easily accessible? The main independent variable is household income, adjusted for household size and split into quintiles, calculating the quintile limits for each country separately. Information on age, sex, self assessed health and chronic disease is included as well. Logistic regression models were used for the multivariate analyses. The overall level of forgone care differs considerably between the five countries (e.g. about 10 percent in Greece and 6 percent in Sweden). Low income groups report forgone care more often than high income groups. This association can also be found in analyses restricted to the subsample of persons with chronic disease. Associations between forgone care and income are particularly strong in Germany and Greece. Taking the example of Germany, forgone care in the lowest income quintile is 1.98 times (95% CI: 1.08–3.63) as high as in the highest income quintile. Forgone care should be reduced even if it is not justified by an 'objective' need for health care, as it could be an independent stressor in its own right, and as patient satisfaction is a strong predictor of compliance. These efforts should focus on population groups with particularly high prevalence of forgone care, for example on patients with poor self assessed health, on women, and on low income groups. The inter-country differences point to the need to specify different policy recommendations for different countries.

/pdf/association-between-forgone-care-and-household-income-among-30qh1xjvtn.pdf

Association between forgone care and household income among the elderly in five Western European countries – analyses based on survey data from the SHARE-study

R. Voellinger

Papers

Healthcare and preventive services utilization of elderly Europeans with depressive symptoms.