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Thesis Defense [06102010]

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  • 1. Mental health status, and the use of mental health services and psychotherapeutic medicines among U.S. cancer survivors and their spouses A Dissertation in Health Policy and Administration And Demography by Rajeshwari S. Punekar
  • 2. Overview
    • Background
    • Objectives
    • Contributions
    • Conceptual Framework
    • Literature Review
    • Methods
      • Data
      • Measures
      • Analysis
    • Results
    • Policy Implications
    • Limitations
  • 3. 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
  • 4. 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.
  • 5. 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
  • 6. 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 cancer
    • Cancer characteristics
      • Cancer site
      • Stage of cancer
      • Recurrence
      • Age at diagnosis
      • Time since diagnosis
      • Type of treatment
    Use of Mental Health Services and Psychotherapeutic Medicines
  • 7. 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
  • 8. 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.
  • 9. 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.
  • 10. 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.
  • 11. 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.
  • 12. Data 1999-2005 NHIS Cancer cases- 1,957 Spouses- 826 2001-2006 MEPS-HC Cancer cases- 679 Spouses- 300 2001-2006 NHIS-MEPS link files
  • 13. 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.
  • 14. Analysis
    • MEPS Person-level Survey Weights
      • Weight Adjustment
        • Adjustment factor 1f = Σ i weight if / weight 1f
      • Post Stratification
        • Raking
      • Rescaling weights
    • Survey Design Adjustment
      • Taylor-series Linearization
  • 15. Descriptive Analysis Individuals a Cancer and non-cancer individuals, below ages of 65 years, are significantly different at p=0.05 level b Cancer and non-cancer individuals, 65 and older, are significantly different at p=0.05 level 12 15 10 17 Psychotherapeutic Medicines Use a,b 10 10 11 16 Mental Health Services Use a 7 9 5 10 Depression a % % % % 5 4 4 6 Non-Specific Psychological Distress (K6) Scores a 52 52 51 49 Mental Component Scores of SF-12 a Non-cancer Cancer Non-cancer Cancer 65 and older 25-64 Outcomes
  • 16. Descriptive Analysis Spouses a Cancer and non-cancer individuals, below ages of 65 years, are significantly different at p=0.05 level b Cancer and non-cancer individuals, 65 and older, are significantly different at p=0.05 level 18 23 16 27 Psychotherapeutic Medicines Use a,b 7 10 9 12 Mental Health Services Use 6 10 4 7 Depression a,b % % % % 3 3 3 4 Non-Specific Psychological Distress (K6) Scores a 53 53 52 50 Mental Component Scores of SF-12 a Non-cancer Cancer Non-cancer Cancer 65 and older 25-64 Outcomes
  • 17. Multivariate Analysis
    • Dependent 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
  • 18. Regression coefficients and Odds Ratios (OR) for the outcome of interests in full sample * Significant at p=0.05 level 1.31* 1.34* 1.23* 1.33* Psychotherapeutic medicines utilization (OR) 1.27 1.01 1.04 1.16 Mental health services utilization (OR) 1.88* 1.77* 1.42* 1.59* Depression (OR) 0.09 0.23* 0.15* 0.23* Psychological distress -0.31 -1.12* -0.42 -1.15* MCS-12 65 and older 25-64 65 and older 25-64 Spouses Individuals Outcomes
  • 19. Regression coefficients for the outcomes of interests in the oncology sample
    • Significant at p=0.05 level
    • Reference group: Breast Cancer Survivors
    0.41 -0.52 0.24 -0.25 Prostate cancer 0.51 -1.29 0.46 -0.48 Lung cancer 0.56 0.32 0.37 0.45* Gynecological cancer -0.68 -0.69 -0.58* -0.16 Colorectal cancer Psychological Distress -1.66 1.07 -1.28 1.51 Prostate cancer 0.26 2.96 0.03 0.92 Lung cancer -3.01 -1.10 -2.25 -2.33* Gynecological cancer -0.12 -0.15 0.22 -0.41 Colorectal cancer MCS-12 65 and older 25-64 65 and older 25-64 Spouses Individuals
  • 20. Odds Ratios (OR) for the outcomes of interests in the oncology sample * Significant at p=0.05 level
  • 21. 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.
  • 22. 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.
  • 23. 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