Social determinants of health adversely affect outcomes in severe mental illness

Patients with severe mental illness, particularly those with schizophrenia who are insured by Medicaid, have significant social risk factors that may adversely affect overall health, according to a study presented at Psych Congress.

“More than 5% of adults in the United States have severe mental illness, including bipolar type I, major depressive disorder and schizophrenia,” Dusica Hadzi Boskovic, MS, director of value and real-world evidence at Otsuka Pharmaceuticals, said during a virtual presentation. “In addition to demographics and clinical risk factors, social determinants of health [SDOH] have been shown to impact access to services for patients with severe mental illness [SMI], as well as health outcomes, such as likelihood of adhering to needed medications.”

In the current retrospective cohort analysis, the researchers analyzed registry data of 1,038,075 commercial and 1,234,371 Medicaid-managed care patients aged 18 years or older between July 1, 2016, and Dec. 31, 2018. They linked SDOH at the nearest neighborhood level, which led to a more precise assignment vs. often used census data. Further, they identified newly diagnosed individuals with one or more inpatient or two or more outpatient claims who had a diagnosis of schizophrenia (n = 70,628), bipolar I disorder (n = 243,286) and major depressive disorder (1,958,532) across both cohorts. The researchers used the first observed diagnosis as the index date, with patients continuously enrolled for at least 6 months pre-index and up to 12 months post-index. They assessed patient characteristics and SDOH at baseline.

Patients with schizophrenia who were commercially insured were approximately 5 years younger, on average, than those who received Medicaid managed care (mean ages, 40.6 years and 45.5 years, respectively. Bipolar I disorder and MDD cohorts had similar mean age, which ranged from 40 years to 44 years. Both groups had schizophrenia populations that were 60% men, whereas the bipolar I disorder and MDD cohorts were mostly female, ranging from 60% to 71%. Boskovic and colleagues reported low Charlson Comorbidity Index scores among all cohorts. They noted hypertension as the most common baseline comorbidity.

Results showed a 3.2 to 4.5 times greater likelihood for patients covered by Medicaid managed care to have an income of less than $30,000 per year. Those with schizophrenia had the greatest likelihood of living below the federal poverty level, at 22.2%.

Patients with schizophrenia who received Medicaid managed care had a greater prevalence of SDOH factors compared with commercially insured patients. For these patients who received Medicaid compared with commercial insurance, 72.3% vs. 55.5% lived alone, 37.1% vs. 49.1% were married, 81.6% vs. 66.9% had a high school education or less, and 7.7% vs. 4.9% were more likely not to speak English well or at all, respectively. Further, patients with schizophrenia had a greater prevalence of SDOH factors compared with those with bipolar I disorder or MDD. All assessed cohorts had a high percentage of patients who lived in areas with a full mental health professional shortage, with those with MDD having the highest percentage.

“Physicians should evaluate and address SDOH to assure optimal quality of care and health outcomes of patients with SMI,” Boskovic said. “Further research will evaluate and compare the impact of SDOH on health care utilization, quality outcomes and cost in SMI populations.”