Outpatient Mental Health Visits Research Articles

First Pregnancy Abortion or Natural Pregnancy Loss: A Cohort Study of Mental Health Services Utilization.

While both induced abortion and natural pregnancy loss have been associated with subsequent mental health problems, population-based studies directly comparing these two pregnancy outcomes are rare. We sought to compare mental health morbidity after an induced abortion or natural loss. Continuously eligible Medicaid beneficiaries age 16 in 1999 were assigned to two cohorts based upon the first pregnancy outcome: abortion (n = 1,331) or natural loss (n = 605). Outcomes were mental health outpatient visits, inpatient hospital admissions and hospital days of stay per patient per year. Average exposure periods before and after the first pregnancy outcome for each cohort were used to adjust the mental health service rates. Prior to the first pregnancy outcome, all three utilization rates were significantly higher for the natural loss cohort compared to the abortion cohort. For the abortion cohort, the per-patient per-year increase from the pre- to post-pregnancy periods was significant for all three rates: 2.04 times for outpatient visits (p < 0.0001), 3.04 times for inpatient admissions (p = 0.0003), and 3.01 times for hospital days of stay (p = 0.0112). None of the pre-to-post rate increases were significant for the natural loss cohort. Higher pre-pregnancy use rates for women who experience a natural pregnancy loss indicate that increased mental health services use following abortion cannot be solely attributed to pre-existing mental illness. Only the abortion cohort, but not the natural loss cohort, experienced significant increases in mental health services use following the first pregnancy outcome.

Changes in Antipsychotic Medication Adherence Among Medicaid Beneficiaries with Schizophrenia During COVID-19.

To identify patterns of medication adherence during the pandemic and factors associated with these patterns among Medicaid-enrolled individuals with schizophrenia who had highly adherent medication use prior to the COVID-19 pandemic. We used Medicaid claims from Philadelphia to identify individuals with schizophrenia ≥ 18years of age, their demographic characteristics, and health service use. We used group trajectory models to identify adherence trends, and ANOVA to examine associations between adherence groups and demographic characteristics and service use. The sample included 1,622 individuals. A 4-group trajectory model best fit our data. Seventy percent of individuals averaged about 92% adherence throughout the study period; 10% experienced a pronounced decline when the pandemic started (pandemic non-adherers); 11% experienced a sharp decline mid-pandemic (late non-adherers); and 9% experienced a sharp decline at the beginning of the pandemic and returned to higher adherence after a year (disrupted adherers). Adherers were least likely to be diagnosed with a substance use disorder, and had more telehealth visits, mental health outpatient visits, and fewer emergency department visits on average. Late non-adherers were more likely than adherers to have substance use disorders and physical health conditions. Pandemic non-adherers had more co-occurring psychiatric disorders than adherers and had the lowest use of case management. Three in ten previously adherent individuals with schizophrenia became less adherent to antipsychotic medications, either at the onset or later in the pandemic. Our findings point to telehealth and case management as critical strategies for treatment engagement, especially during public health crises, and well as the need to address co-occurring conditions.

Socioeconomic inequity in the utilization of healthcare among people with eating disorders in Australia.

Little is known about socioeconomic equity in access to healthcare among people with eating disorders in Australia. This study aims to measure the extent of inequity in eating disorder-related healthcare utilization, analyze trends, and explore the sources of inequalities using New South Wales (NSW) administrative linked health data for 2005 to 2020. Socioeconomic inequities were measured using concentration index approach, and decomposition analysis was conducted to explain the factors accounting for inequality. Healthcare utilization included: public inpatient admissions, private inpatient admissions, visits to public mental health outpatient clinics and emergency department visits, with three different measures (probability of visit, total and conditional number of visits) for each outcome. Private hospital admissions due to eating disorders were concentrated among individuals from higher socioeconomic status (SES) from 2005 to 2020. There was no significant inequity in the probability of public hospital admissions for the same period. Public outpatient visits were utilized more by people from lower SES from 2008 to 2020. Emergency department visits were equitable, but more utilized by those from lower SES in 2020. Public hospital and emergency department services were equitably used by people with eating disorders in NSW, but individuals from high SES were more likely to be admitted to private hospitals for eating disorder care. Use of public hospital outpatient services was higher for those from lower SES. These findings can assist policymakers in understanding the equity of the healthcare system and developing programs to improve fairness in eating disorder-related healthcare in NSW.

Association Between Extreme Heat and Outpatient Visits for Mental Disorders: A Time-Series Analysis in Guangzhou, China.

Previous evidence on heatwaves' impact on mental health outpatient visits is limited, especially uncertainty on how different heatwave definitions affect this relationship. In this time-series study, we assessed the association between heatwaves and outpatient visits for mental disorders in Guangzhou, China. Daily outpatient visits for mental disorders and its specific categories (schizophrenia, mood, and neurotic disorders) were sourced from the Urban Resident-based Basic Medical Insurance (URBMI) and the Urban Employee-based Basic Medical Insurance (UEBMI) claims databases in Guangzhou from 2010 to 2014. The study employed nine heatwave definitions, based on combinations of three daily mean temperature thresholds (90th, 92.5th, and 95th percentiles) and durations (2, 3, and 4days). Using quasi-Poisson generalized linear models (GLMs), we estimated the risks (at lag 0day) and cumulative effects (lag 0-10days) of heatwaves on mental disorder outpatient visits. Age, gender, types of medical insurance were considered as potential effect modifiers. We observed a positive association between heatwaves and increased total outpatient visits for mental disorders, both at lag 0day and during lag 0-10days. The impact of heatwave was significant at lag 0day for schizophrenia, mood and neurotic disorders visits, it remained significant for neurotic and mood disorders visits during lag 0-10days. Heatwave durations lasting more than 4days were associated with higher relative risks of mental disorders at lag 0day. Older adults had relatively higher effect estimations than younger individuals. This research highlights the effects of extreme heat on mental health.

High Out-of-Pocket Cost Burden of Mental Health Care for Adult Outpatients in the United States.

This report describes characteristics of patients who had high out-of-pocket (OOP) spending on mental health care relative to income. A sample of 8,923 U.S. adults with outpatient mental health visits was drawn from the 2018-2021 Medical Expenditure Panel Survey. Respondents who spent ≥10% of their disposable family incomes on OOP mental health visits were defined as having a high OOP cost burden. Using weighted percentages, the authors found that 2.4% of psychiatric outpatients had a high OOP burden; among those below the federal poverty level, 12.8% had a high OOP burden. Patients with a high (vs. low) OOP burden were statistically significantly more likely to be uninsured (7.5% vs. 2.4%) or diagnosed as having a substance use disorder (8.7% vs. 2.8%) or bipolar disorder (14.5% vs. 8.0%). Despite federal policies extending the availability of insurance for mental health care, many low-income psychiatric outpatients experience high OOP cost burden.

Factors associated with electroconvulsive therapy treatment for adults with serious psychiatric conditions in Australia.

To identify factors associated with receiving electroconvulsive therapy (ECT) for serious psychiatric conditions. Retrospective observational study using hospital administrative data linked with death registrations and outpatient mental health data in New South Wales (NSW), Australia. The cohort included patients admitted with a primary psychiatric diagnosis between 2013 and 2022. The outcome measure was receipt of ECT. Of 94,950 patients, 3465 (3.6%) received ECT. The likelihood of receiving ECT was higher in older (hazard ratio [HR] = 1.03), female (HR = 1.24) patients. Compared to depression, patients with schizophrenia/schizoaffective disorder (HR = 0.79), schizophrenia-related disorders (HR = 0.37), mania (HR = 0.64) and other mood disorders (HR = 0.45) had lower odds of receiving ECT. Patients with depression and one other serious psychiatric condition had higher odds of receiving ECT than depression alone. Bipolar disorder likelihood of ECT did not differ from depression. A higher number of mental health outpatient visits in the prior year and an involuntary index admission with depression were also associated with receiving ECT. Likelihood of receiving ECT increased with year of admission (HR = 1.32), private patient status (HR = 2.06), higher socioeconomic status (HR = 1.09) and being married (HR = 1.25). ECT use for depression and bipolar disorder in NSW aligns with clinical national guidelines. Patients with schizophrenia/schizoaffective, schizophrenia-related disorders, mania and other mood disorders had lower likelihood of ECT than depression, despite ECT being recommended by clinical guidelines for these diagnoses. Variations in ECT were strongly associated with healthcare access, with private patients twice as likely to receive ECT than their public counterparts, suggesting a need to explore ECT accessibility.

Differential impacts of the COVID-19 pandemic on mental health service access among Medicaid-enrolled individuals.

The COVID-19 public health emergency (PHE) caused significant disruptions in the delivery of care, with in-person visits decreasing and telehealth use increasing. We investigated the impact of these changes on mental health services for Medicaid-enrolled adults and youth in Washington State. Among enrollees with existing mental health conditions, the first year of the PHE was associated with a surge in specialty outpatient mental health visits (13% higher for adults and 7% higher for youth), returning to pre-PHE levels in the second year. Conversely, youth with new mental health needs experienced a decline in specialty outpatient visit rates by ∼15% and 37% in the first and second years of the PHE, respectively. These findings indicate that while mental health service use was maintained or improved for established patients, these patterns did not extend to Medicaid-enrolled youth with new mental health needs, potentially due to barriers such as difficulty in finding providers and establishing new patient-provider relationships remotely. To bridge this gap, there is a need for a multi-faceted approach that includes improving service accessibility, enhancing provider availability, and optimizing initial care encounters, whether in-person or virtual, to better support new patients.

Mental health care use and quality among Medicaid adults with serious mental illness receiving care at Federally Qualified Health Centers vs. other settings

BackgroundFederally Qualified Health Centers (FQHCs) are a critical source of care for medically underserved populations and often serve as medical homes for individuals with serious mental illness (SMI). Many FQHCs provide mental health services and could facilitate access to mental health treatment within and outside of FQHCs. This study compared mental health care utilization and acute care events for adult Medicaid enrollees with SMI who receive care at Federally Qualified Health Centers (FQHCs) vs. other settings.MethodsThis study used the 2015–2016 Massachusetts All-Payer Claims Database to examine outpatient mental health care and acute care events for 32,330 Medicaid adults, ages 18–64 and with major depressive, bipolar, or schizophrenia spectrum disorders (SSD), who resided in FQHC service areas and received care from FQHCs vs. other settings in 2015. Multivariable linear regressions assessed associations between receiving care at FQHCs and outpatient mental health visits, psychotropic medication fills, and acute care events in 2016.ResultsThere were 8,887 (27.5%) adults in the study population (N = 32,330) who had at least one FQHC visit in 2015. Those who received care at FQHCs were more likely to have outpatient mental health visits (73.3% vs. 71.2%) and psychotropic medication fills (73.2% vs. 69.0%, both p < .05), including antidepressants among those with depressive disorders and antipsychotics among those with SSD. They were more likely to have ED visits (74.0% vs. 68.7%), but less likely to be hospitalized (27.8% vs. 31.9%, both p < .05). However, there was no significant difference in the likelihood of having an acute psychiatric hospitalization (9.5% vs. 9.8%, p = .35).ConclusionsAmong Medicaid enrollees with SMIs who had access to care at FQHCs, those receiving care at FQHCs were more likely to have outpatient mental health visits and psychotropic medication fills, with lower rates of hospitalization, suggesting potentially improved quality of outpatient care. Higher ED visit rates among those receiving care at FQHCs warrant additional investigation.

Validation of a Multivariable Model to Predict Suicide Attempt in a Mental Health Intake Sample

Given that suicide rates have been increasing over the past decade and the demand for mental health care is at an all-time high, targeted prevention efforts are needed to identify individuals seeking to initiate mental health outpatient services who are at high risk for suicide. Suicide prediction models have been developed using outpatient mental health encounters, but their performance among intake appointments has not been directly examined. To assess the performance of a predictive model of suicide attempts among individuals seeking to initiate an episode of outpatient mental health care. This prognostic study tested the performance of a previously developed machine learning model designed to predict suicide attempts within 90 days of any mental health outpatient visit. All mental health intake appointments scheduled between January 1, 2012, and April 1, 2022, at Kaiser Permanente Northern California, a large integrated health care delivery system serving over 4.5 million patients, were included. Data were extracted and analyzed from August 9, 2022, to July 31, 2023. Suicide attempts (including completed suicides) within 90 days of the appointment, determined by diagnostic codes and government databases. All predictors were extracted from electronic health records. The study included 1 623 232 scheduled appointments from 835 616 unique patients. There were 2800 scheduled appointments (0.17%) followed by a suicide attempt within 90 days. The mean (SD) age across appointments was 39.7 (15.8) years, and most appointments were for women (1 103 184 [68.0%]). The model had an area under the receiver operating characteristic curve of 0.77 (95% CI, 0.76-0.78), an area under the precision-recall curve of 0.02 (95% CI, 0.02-0.02), an expected calibration error of 0.0012 (95% CI, 0.0011-0.0013), and sensitivities of 37.2% (95% CI, 35.5%-38.9%) and 18.8% (95% CI, 17.3%-20.2%) at specificities of 95% and 99%, respectively. The 10% of appointments at the highest risk level accounted for 48.8% (95% CI, 47.0%-50.6%) of the appointments followed by a suicide attempt. In this prognostic study involving mental health intakes, a previously developed machine learning model of suicide attempts showed good overall classification performance. Implementation research is needed to determine appropriate thresholds and interventions for applying the model in an intake setting to target high-risk cases in a manner that is acceptable to patients and clinicians.

Is adequate dose adequate? An examination of the impact of psychotherapy on posttraumatic stress disorder symptoms utilizing Veterans Health Administration medical records.

Prior studies on individuals with posttraumatic stress disorder (PTSD) defined an adequate dose of psychotherapy as receiving at least nine sessions within a 15-week period. Yet, few studies have examined whether this definition of adequate dose is associated with meaningful change in PTSD symptoms over an extended period. To examine whether an adequate dose of individual or group psychotherapy was associated with PTSD symptom improvement, we identified mental health outpatient visits in the electronic medical record for a cohort of veterans enrolled in Veterans Health Administration (VHA) services (N = 1,649) across 5 years. Using latent growth curve modeling, we estimated the effect of receiving an adequate dose of psychotherapy on the PTSD symptom course. Among the sample, 992 participants (60.16%) received at least one individual therapy session and 506 participants (30.7%) received at least one group therapy session; of those, 226 (22.78%) received an adequate dose of individual therapy and 212 (41.9%) received an adequate dose of group therapy, respectively. An adequate individual therapy dose, but not group therapy dose, was associated with a decrease in PTSD Checklist for DSM-5 (PCL-5) scores over time. This improvement was extremely gradual (average of 1.57 PCL-5 point decrease per year). Adequate dose of psychotherapy, defined as nine sessions of routine psychotherapy over 15 weeks, is associated with minimal symptom change. This suggests that commonly used definitions of adequate dose have minimal clinical utility. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Social Risk Factors and Racial and Ethnic Disparities in Health Care Resource Utilization Among Medicare Advantage Beneficiaries With Psychiatric Disorders.

The intersection of social risk and race and ethnicity on mental health care utilization is understudied. This study examined disparities in health care treatment, adjusting for clinical need, among 25,780 Medicare Advantage beneficiaries with a diagnosis of a psychiatric disorder. We assessed contributions to disparities from racial and ethnic differences in the composition and returns of social risk variables. Black and Hispanic beneficiaries had lower rates of mental health outpatient visits than Whites. Assessing composition, Black and Hispanic beneficiaries experienced greater financial, food, and housing insecurity than White beneficiaries, factors associated with greater mental health treatment. Assessing returns, food insecurity was associated with an exacerbation of Hispanic-White disparities. Health care systems need to address the financial, food and housing insecurity of racial and ethnic minority groups with psychiatric disorder. Accounting for racial and ethnic differences in social risk adjustment-based payment reforms has significant implications for provider reimbursement and outcomes.

New and continuing physician-based outpatient mental health care among children and adolescents during the COVID-19 pandemic in Ontario, Canada: a population-based study.

To assess physician-based mental health care utilization during the COVID-19 pandemic among children and adolescents new to care and those already engaged with mental health services, and to evaluate differences by sociodemographic factors. We performed a population-based repeated cross-sectional study using linked health and administrative databases in Ontario, Canada among all children and adolescents 3-17 years. We examined outpatient visit rates per 1,000 population for mental health concerns for those new to care (no physician-based mental healthcare for ≥1 year) and those with continuing care needs (any physician-based mental healthcare <1 year) following onset of the pandemic. Among ~2.5 million children and adolescents (48.7% female, mean age 10.1 ± 4.3 years), expected monthly mental health outpatient visits were 1.5/1,000 for those new to mental health care and 5.4/1,000 for those already engaged in care. Following onset of the pandemic, visit rates for both groups were above expected [adjusted rate ratio (aRR) 1.22, 95% CI 1.17, 1.27; aRR 1.10, 95% CI 1.07, 1.12] for new and continuing care, respectively. The greatest increase above expected was among females (new: aRR 1.33, 95% CI 1.25, 1.42; continuing: aRR 1.22 95% CI 1.17, 1.26) and adolescents ages 13-17 years (new: aRR 1.31, 95% CI 1.27, 1.34; continuing: aRR 1.15 95% CI 1.13, 1.17). Mood and anxiety concerns were prominent among those new to care. In the 18 months following onset of the pandemic, outpatient mental health care utilization increased for those with new and continuing care needs, especially among females and adolescents.

Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms

IntroductionPrior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits. MethodsUsing electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups. ResultsAmong patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59–0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter. ConclusionsThis study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.

Linkage of whole genome sequencing and administrative health data in autism: A proof of concept study.

Whether genetic testing in autism can help understand longitudinal health outcomes and health service needs is unclear. The objective of this study was to determine whether carrying an autism-associated rare genetic variant is associated with differences in health system utilization by autistic children and youth. This retrospective cohort study examined 415 autistic children/youth who underwent genome sequencing and data collection through a translational neuroscience program (Province of Ontario Neurodevelopmental Disorders Network). Participant data were linked to provincial health administrative databases to identify historical health service utilization, health care costs, and complex chronic medical conditions during a 3-year period. Health administrative data were compared between participants with and without a rare genetic variant in at least 1 of 74 genes associated with autism. Participants with a rare variant impacting an autism-associated gene (n = 83, 20%) were less likely to have received psychiatric care (at least one psychiatrist visit: 19.3% vs. 34.3%, p = 0.01; outpatient mental health visit: 66% vs. 77%, p = 0.04). Health care costs were similar between groups (median: $5589 vs. $4938, p = 0.4) and genetic status was not associated with odds of being a high-cost participant (top 20%) in this cohort. There were no differences in the proportion with complex chronic medical conditions between those with and without an autism-associated genetic variant. Our study highlights the feasibility and potential value of genomic and health system data linkage to understand health service needs, disparities, and health trajectories in individuals with neurodevelopmental conditions.

Effects of Geography on Risk for Future Suicidal Ideation and Attempts Among Children and Youth

Geography may influence the relationships of predictors for suicidal ideation (SI) and suicide attempts (SA) in children and youth. This is a nationwide retrospective cohort study of 124,424 individuals less than 25 years of age using commercial claims data (2011-2015) from the Health Care Cost Institute. Outcomes were time to SI or SA within 3 months after the indexed mental health or substance use disorder (MH/SUD) outpatient visit. Predictors included sociodemographic and clinical characteristics up to 3 years before the index event. At each follow-up time period, rates of SI and SA varied by the US geographic division (p < .001), and the Mountain Division consistently had the highest rates for both SI and SA (5.44%-10.26% for SI; 0.70%-2.82% for SA). Having MH emergency department (ED) visits in the past year increased the risk of SI by 28% to 65% for individuals residing in the New England, Mid-Atlantic, East North Central, West North Central, and East South Central Divisions. The main effects of geographic divisions were significant for SA (p<0.001). Risk of SA was lower in New England, Mid-Atlantic, South Atlantic, and Pacific (hazard ratios = 0.57, 0.51, 0.67, and 0.79, respectively) and higher in the Mountain Division (hazard ratio = 1.46). To understand the underlying mechanisms driving the high prevalence of SI and SA in the Mountain Division and the elevated risk of SI after having MH ED visits, future research examining regional differences in risks for SI and SA should include indicators of access to MH ED care and other social determinants of health.

Timing of Mental Health Service Use After a Pediatric Firearm Injury.

To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics. We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics. After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65). More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

A Cohort Study of Mental Health Services Utilization Following a First Pregnancy Abortion or Birth.

To determine whether exposure to a first pregnancy outcome of induced abortion, compared to a live birth, is associated with an increased risk and likelihood of mental health morbidity. Participants were continuously eligible Medicaid beneficiaries age 16 in 1999, and assigned to either of two cohorts based upon the first pregnancy outcome, abortion (n = 1331) or birth (n = 3517), and followed through to 2015. Outcomes were mental health outpatient visits, inpatient hospital admissions, and hospital days of stay. Exposure periods before and after the first pregnancy outcome, a total of 17 years, were determined for each cohort. Women with first pregnancy abortions, compared to women with births, had higher risk and likelihood of experiencing all three mental health outcome events in the transition from pre- to post-pregnancy outcome periods: outpatient visits (RR 2.10, CL 2.08-2.12 and OR 3.36, CL 3.29-3.42); hospital inpatient admissions (RR 2.75, CL 2.38-3.18 and OR 5.67, CL 4.39-7.32); hospital inpatient days of stay (RR 7.38, CL 6.83-7.97 and OR 19.64, CL 17.70-21.78). On average, abortion cohort women experienced shorter exposure time before (6.43 versus 7.80 years), and longer exposure time after (10.57 versus 9.20 years) the first pregnancy outcome than birth cohort women. Utilization rates before the first pregnancy outcome, for all three utilization events, were higher for the birth cohort than for the abortion cohort. A first pregnancy abortion, compared to a birth, is associated with significantly higher subsequent mental health services utilization following the first pregnancy outcome. The risk attributable to abortion is notably higher for inpatient than outpatient mental health services. Higher mental health utilization before the first pregnancy outcome for birth cohort women challenges the explanation that pre-existing mental health history explains mental health problems following abortion, rather than the abortion itself.

Mental health and addiction health service use by physicians compared to non-physicians before and during the COVID-19 pandemic: A population-based cohort study in Ontario, Canada.

The Coronavirus Disease 2019 (COVID-19) pandemic has exacerbated mental health challenges among physicians and non-physicians. However, it is unclear if the worsening mental health among physicians is due to specific occupational stressors, reflective of general societal stressors during the pandemic, or a combination. We evaluated the difference in mental health and addictions health service use between physicians and non-physicians, before and during the COVID-19 pandemic. We conducted a population-based cohort study in Ontario, Canada between March 11, 2017 and August 11, 2021 using data collected from Ontario's universal health system. Physicians were identified using registrations with the College of Physicians and Surgeons of Ontario between 1990 and 2020. Participants included 41,814 physicians and 12,054,070 non-physicians. We compared the first 18 months of the COVID-19 pandemic (March 11, 2020 to August 11, 2021) to the period before COVID-19 pandemic (March 11, 2017 to February 11, 2020). The primary outcome was mental health and addiction outpatient visits overall and subdivided into virtual versus in-person, psychiatrists versus family medicine and general practice clinicians. We used generalized estimating equations for the analyses. Pre-pandemic, after adjustment for age and sex, physicians had higher rates of psychiatry visits (aIRR 3.91 95% CI 3.55 to 4.30) and lower rates of family medicine visits (aIRR 0.62 95% CI 0.58 to 0.66) compared to non-physicians. During the first 18 months of the COVID-19 pandemic, the rate of outpatient mental health and addiction (MHA) visits increased by 23.2% in physicians (888.4 pre versus 1,094.7 during per 1,000 person-years, aIRR 1.39 95% CI 1.28 to 1.51) and 9.8% in non-physicians (615.5 pre versus 675.9 during per 1,000 person-years, aIRR 1.12 95% CI 1.09 to 1.14). Outpatient MHA and virtual care visits increased more among physicians than non-physicians during the first 18 months of the pandemic. Limitations include residual confounding between physician and non-physicians and challenges differentiating whether observed increases in MHA visits during the pandemic are due to stressors or changes in health care access. The first 18 months of the COVID-19 pandemic was associated with a larger increase in outpatient MHA visits in physicians than non-physicians. These findings suggest physicians may have had larger negative mental health during COVID-19 than the general population and highlight the need for increased access to mental health services and system level changes to promote physician wellness.

The association between mental illness and all-cause mortality in patients with cirrhosis: a Veterans Affairs retrospective cohort study.

Mental health diagnoses are common and known to impact key outcomes in patients with chronic illnesses including cirrhosis. However, the independent impact of psychiatric comorbidities on mortality in these patients and potential mitigating effects of outpatient mental health-related care has not been well characterized. This was a retrospective cohort study of patients with cirrhosis in the Veterans Health Administration between 2008 and 2021. Adjusted Cox regression was performed to evaluate the association between mental health-related diagnoses [groups: alcohol use disorder (AUD)/substance use disorder (SUD) alone, non-AUD/SUD alone, and any mental health diagnosis (AUD/SUD or non-AUD/SUD)] and all-cause mortality. In subgroup analyses, the impact of regular outpatient mental health visits was also assessed. We identified 115,409 patients, 81.7% of whom had any mental health diagnosis at baseline. During the study window there was a significant increase in the number of mental health clinic visits per person-year (β=0.078, 95% CI: 0.065-0.092, p < 0.001), but a decrease in AUD/SUD clinic utilization (p < 0.001). In regression models, there was a 54% increased hazard in all-cause mortality for any mental health diagnosis, 11% for non-AUD/SUD, and 44% for AUD/SUD (each p < 0.001). Regular mental health visits resulted in a 21% decreased risk in all-cause mortality for AUD/SUD diagnosis, compared with 3% and 9% for any mental health diagnosis and non-AUD/SUD diagnosis, respectively (each p < 0.001). Mental illness is associated with an increased risk of all-cause mortality in veterans with cirrhosis. Regular outpatient mental health care may be protective against all-cause mortality, particularly among patients with AUD/SUD. Future studies should focus on relevant clinical practice changes, including implementing integrated care programs.

Impact of New York State's Health Home Model on Health Care Utilization.

The Affordable Care Act established Medicaid health homes to provide care management and coordination for high-need individuals, including many with serious mental illness. The authors used data from the Medicaid Data Warehouse to examine health care utilization over 3 years among 10,193 individuals who enrolled in a New York State health home and had at least one outpatient mental health visit during the year prior to enrollment. Results for postenrollment year 2 indicated a 43% decrease in inpatient mental health discharges, a 38% decrease in substance use discharges, and a 7% reduction in general medical discharges, whereas mental health outpatient treatment and behavioral and nonbehavioral medication utilization increased. Further research is needed to determine the effectiveness of health home care management for individuals with serious mental illness.