Abstract
Objective
To examine the odds associated with having medical comorbidities among patients with serious mental illness (SMI) in a large integrated health system.
Method
In a secondary analysis of electronic health record data, this study identified 25,090 patients with an ICD-9 SMI diagnosis of bipolar disorder (n = 20,308) or schizophrenia (n = 4,782) and 25,090 controls who did not have a SMI, matched on age, gender, and medical home facility. Conditional logistic regressions compared the odds associated with having nine medical comorbidity categories and fifteen chronic or serious conditions among patients with SMI versus controls.
Results
Results showed having a SMI was associated with significantly higher odds of each medical comorbidity examined (p’s < .001), except no evidence of a significant association was found between having schizophrenia and musculoskeletal diseases. A similar pattern was found regarding the chronic or severe conditions, where having schizophrenia or bipolar was associated with >1.5 times the odds of each condition (p’s < .001).
Conclusions
In an integrated health system where patients may have fewer barriers to care, SMI patients are likely to present for treatment with a range of medical comorbidities, including chronic and severe conditions. SMI patients may need outreach strategies focused on disease prevention, screening and early diagnosis, and treatment to address medical comorbidities and associated poor health outcomes.
Keywords: serious mental illness, health systems, chronic conditions, medical comorbidity
INTRODUCTION
Serious mental illnesses (SMI), which typically include bipolar disorders and schizophrenia, are characterized as chronic and debilitating conditions that place significant burdens on patients, as well as their families and society. Despite the marked improvement in managing destabilizing symptoms that followed the introduction of psychotropic medications,1 most patients who suffer from a SMI continue to have a limited recovery and experience poor physical health.2–5 Fifty to 80%6–8 of individuals with SMI have one or more comorbid medical conditions that may worsen prognosis and contribute to high morbidity and premature mortality.3,9–10 More concerning is that over 60% of the medical comorbidities observed among persons with SMIs are non-fatal and preventable, yet these persons have 15 to 25 years shorter expectancy relative to the general population.11 Unfortunately, the medical needs of those with SMI are often neglected,12 which may partly explain the reason for why their morbidity and mortality are elevated.
Studies of modifiable risk factors suggest that risky sexual behaviors and poor hygiene,13,14 are linked with higher risk of genitourinary, infectious, and blood borne diseases among individuals with SMIs. Increased rates of alcohol and illicit drug use,13 smoking,14–17 poor nutrition and lack of exercise,18 may be associated with higher rates of cardiovascular and respiratory 8,10,13,15,19 conditions; and genitourinary and metabolic8,10,13,16,19–20 diseases. Patients with SMI also present for treatment with a number of serious and chronic medical conditions (i.e., hypertension, asthma, obesity, chronic obstructive pulmonary disease, epilepsy),2,4,21 and these conditions can onset up to 10 years earlier in this population compared to age-matched controls.22 In addition, having medical comorbidities place SMI patients at risk of repeat hospital visits that raise health care costs and increase the burden of disease.4,23–24 Not surprisingly, the problem of medical comorbidities in SMI is now considered a major public health issue due to its destabilizing effects and high cost to families and society.12
Patients with SMI continue to experience elevated morbidity despite the identification of several preventable and modifiable risk factors for poor health. Thus, a study that seeks to examine associations among patients with SMI and odds of having medical comorbidities in a large integrated health system is important to inform patient care. In this study, we examined associations among 25,090 patients with a SMI diagnosis of bipolar disorder or schizophrenia and odds of having medical comorbidities relative to 25,090 patients without an SMI in a large health system. Importantly, to inform patient care planning we examined acute conditions, which are more likely to require immediate medical attention as well as severe or chronic conditions necessitating ongoing monitoring and management.
METHODS
Setting
Kaiser Permanente of Northern California (KPNC) is a nonprofit, integrated health care delivery system providing health care services to more than 4 million members, serving 45% of the commercially insured population in the region. KPNC consists of a health care plan, a sole medical group, and a hospital system. Specialty health services, such as psychiatry, substance use treatment, and other specialty care, are available to all members internally. To facilitate integrated health care services, providers have access to a mature electronic health record (EHR) system with each member’s medical history, including primary care, emergency department, ambulatory, hospital and specialty health care encounters. In KPNC, about 88% of members are commercially insured, 28% have Medicare and 10% have Medicaid coverage. All patients were selected from the KPNC membership for this study. Institutional review board approval was obtained from the Kaiser Foundation Research Institute.
Participants
We used EHR data for this secondary, database study. These data were used to identify all health system members who 1) were at least 18 years of age, 2) had a visit to a KPNC facility in 2010, and 3) had a recorded ICD-9 diagnosis of schizophrenia or bipolar disorder in 2010. The first mention of each ICD-9 diagnosis of schizophrenia or bipolar recorded from January 1, 2010 to December 2010 were included; patients in the sample could have multiple diagnoses (e.g., the SMI groups were not mutually exclusive). We also included all current or existing behavioral health diagnoses that were additionally documented for patients with schizophrenia or bipolar during health system visits in 2010 (see Appendix A for a complete list of ICD-9 codes).
EHR data were also used to identify control patients without current or existing behavioral health diagnoses. Control patients were selected for all unique patients with bipolar disorder or schizophrenia, and matched one-to-one on gender, age, and medical home facility (e.g., the medical center where they typically receive care). This method accounted for any differences in services, types of conditions, or unobservable differences by geographic location.
The final analytical sample consisted of 50,180 patients: 20,308 with bipolar disorder, 4,782 with schizophrenia, and 25, 090 controls. Institutional review board approval was obtained from the Kaiser Foundation Research Institute.
Measures
Patient characteristics
Age, gender, race/ethnicity, patient medical home facility, census based median neighborhood household income, and ICD-9 psychiatric and medical diagnoses were extracted from the EHR. Race/ethnicity consisted of five categories: white, Black, Hispanic, Asian, and other. Psychiatric and medical diagnoses were determined based on ICD-9 diagnoses noted during visits made over the study period and included current and existing diagnoses.
Medical Comorbidities
Medical ICD-9 diagnoses were extracted from the EHR for nine disease categories previously classified as common in SMI populations based on prior research.2–5,13–14 Dichotomous measures (1 = present; 0 = else) were computed for the nine medical conditions: diseases of the blood/blood and forming organs; diseases of the circulatory system; diseases of the digestive system; endocrine/immunity diseases; genitourinary diseases; infectious/parasitic diseases; diseases of the musculoskeletal system; diseases of the nervous system; and diseases of the respiratory system (see Appendix A).
Severe or chronic medical conditions
Using the EHR, we extracted fifteen ICD-9 disease categories for the severe or chronic medical conditions that are considered prevalent in SMI populations based on prior research.2,4,8,21 Dichotomous measures (1 = present; 0 = else) were computed for each severe/chronic medical condition: acid-peptic disorders; arthritis; asthma; chronic kidney disease; chronic pain; chronic obstructive pulmonary disease; coronary atherosclerosis; diabetes mellitus; hepatitis C; hypertension; injury poisoning/overdose; ischemic heart disease; pneumonia; obesity; and stroke. An indicator (any severe/chronic medical condition: 1 = present; 0 = else) identified those with ≥1 of the fifteen chronic conditions.
Analyses
Frequencies and means were used to characterize the sample. We used McNemar’s test (categorical) and paired sample t-tests (continuous) to determine potential differences between the matched samples of patients with SMI and controls. These analyses proceeded by examining potential differences between patients with SMI (e.g., bipolar and schizophrenia) compared to controls by age, gender, race/ethnicity and income. A series of conditional logistic regressions were then computed, predicting each of nine medical condition categories (1 = present; 0 = else) from bipolar or schizophrenia (reference = controls), to compare the odds associated with having medical comorbidities in patients with SMI compared to controls. We then computed a series of conditional logistic regressions predicting each of fifteen chronic or severe medical conditions (1 = present; 0 = else) from having bipolar or schizophrenia (reference = controls), to compare the odds of having chronic or severe medical comorbidities in SMI patients versus controls. All conditional logistic regressions adjusted for race/ethnicity and income. SMI and control samples were matched 1-to-1 on age and gender; and thus, no significant differences were anticipated or found between matched groups regarding these relationships (all p = 1.00). Conditional logistic regressions were computed without controlling for age or gender. The Hochberg25 method was used to adjust for multiple inference testing within each medical condition category. We report Hochberg adjusted p-values for the conditional logistic regressions comparing the odds of having medical comorbidities for patients with SMI and controls. Statistical significance was defined at p < .05; analyses were performed using R version 2.15.0.26
RESULTS
Patient characteristics
Overall, the sample was 70.0% women, 60.0% White, 15.6% Hispanic, 12.2% Asian, 7.4% Black, 4.8% other race/ethnicity. Patients were 49 years old on average, (not shown). As shown in Table 1, more patients with schizophrenia or bipolar were white compared to controls; fewer controls were Hispanic, Asian, or Black relative to patients with schizophrenia or bipolar. However, more patients with schizophrenia were Black relative controls. On average, patients with bipolar or schizophrenia lived in lower income neighborhoods compared to controls. Since patients were matched on age and gender, no evidence of differences across these measures were found among the controls and the patients with schizophrenia or bipolar (Table 1).
Table 1.
Patient characteristics.
| Variable | Bipolar | Control | Schizophrenia | Control | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n = 20,308 | n = 20,308 | n = 4,782 | n = 4,782 | |||||||
|
| ||||||||||
| N | % | N | % | pa | N | % | N | % | pa | |
| Race/Ethnicity | ||||||||||
| White | 14331 | 70.5 | 10444 | 51.4 | <.001 | 2580 | 53.9 | 2371 | 49.5 | .017 |
| Hispanic | 2433 | 11.9 | 3400 | 16.9 | <.001 | 626 | 13.0 | 780 | 16.3 | <.001 |
| Asian | 1248 | 6.1 | 3403 | 16.7 | <.001 | 615 | 12.8 | 828 | 17.3 | <.001 |
| Black | 1459 | 7.1 | 1592 | 7.8 | <.001 | 768 | 16.0 | 474 | 9.9 | <.001 |
| Unknown | 837 | 4.1 | 1429 | 7.0 | <.001 | 193 | 4.0 | 329 | 6.8 | <.001 |
| Male | 7373 | 36.3 | 7374 | 36.3 | ns | 2356 | 49.2 | 2356 | 49.2 | ns |
| Age M, SD | 45.2 | 16.0 | 45.3 | 16.0 | ns | 47.3 | 16.2 | 47.3 | 16.2 | ns |
| Income M, SD | 60K | 25019 | 61K | 24653 | <.001 | 57K | 24971 | 61K | 24304 | <.001 |
Note. Control patients were matched one-to-one on gender, age, and medical home facility to patients with bipolar or schizophrenia, respectively. ns = non-significant p-values were equal to 1 for gender and age as patients were matched based on these variables. Income = neighborhood income.
McNemar’s χ2 test or paired sample t-test (two-tailed).
Medical comorbidities and chronic medical conditions
As shown in Table 2, having a SMI was largely associated with higher odds of medical comorbidities, with few exceptions. Having bipolar was associated with higher odds of blood/blood forming organ diseases (OR = 2.21, p < .001), digestive system diseases (OR = 2.22, p < .001), and endocrine/immunity diseases (OR = 2.34, p < .001), compared to controls. Likewise, schizophrenia was associated with >2 times the odds of diseases of the blood/blood forming organs (OR = 2.21, p < .001), digestive system diseases (OR = 2.22, p < .001), and (OR = 2.97, p < .001) and endocrine/immunity diseases. Schizophrenia and bipolar were both associated with >1.5 times the odds of diseases of the circulatory, respiratory, and nervous systems as well as infectious/parasitic and genitourinary diseases. Bipolar was also associated with >1.5 times the odds of musculoskeletal diseases; however, no evidence of a significant difference was found between having schizophrenia and musculoskeletal diseases (Table 2).
Table 2.
Conditional logistic regression models examining associations among patients with serious mental illness and medical conditions compared to controls.
| Disease/Condition Category | Bipolar | Schizophrenia | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| n = 20,308 | n = 4,782 | |||||||
|
|
|
|||||||
| ORa | 95% CI | SE | pb | ORa | 95% CI | SE | pb | |
| Blood/Blood Forming Organs | 2.21 | 2.02, 2.41 | 0.04 | <.001 | 2.71 | 2.29, 3.21 | 0.08 | <.001 |
| Circulatory System | 1.70 | 1.61, 1.79 | 0.02 | <.001 | 1.86 | 1.68, 2.06 | 0.05 | <.001 |
| Digestive System | 2.22 | 2.11, 2.34 | 0.02 | <.001 | 2.19 | 1.99, 2.42 | 0.05 | <.001 |
| Endocrine/Immunity | 2.34 | 2.22, 2.46 | 0.02 | <.001 | 2.97 | 2.69, 3.28 | 0.05 | <.001 |
| Genitourinary | 1.84 | 1.75, 1.93 | 0.02 | <.001 | 1.59 | 1.44, 1.76 | 0.05 | <.001 |
| Infectious/Parasitic | 1.78 | 1.68, 1.89 | 0.03 | <.001 | 1.59 | 1.41, 1.79 | 0.06 | <.001 |
| Musculoskeletal | 1.90 | 1.81, 1.98 | 0.02 | <.001 | 1.07 | 0.98, 1.17 | 0.04 | .127 |
| Nervous System | 1.94 | 1.85, 2.03 | 0.02 | <.001 | 1.59 | 1.46, 1.74 | 0.04 | <.001 |
| Respiratory System | 1.68 | 1.61, 1.76 | 0.02 | <.001 | 1.50 | 1.34, 1.61 | 0.04 | <.001 |
Note. All conditional logistic regression models adjusted for race/ethnicity and neighborhood income.
Reference group = Control patients. Patients with bipolar and schizophrenia were matched to control patients, one-to-one on gender, age, and medical home facility.
P-values were adjusted for multiple inference testing using the Hochberg25 method.
Table 3 presents results of conditional logistic regressions comparing the odds associated with having a SMI and severe or chronic medical conditions. A diagnosis of bipolar disorder or schizophrenia were both associated with higher odds of ≥1 severe or chronic medical conditions. Having bipolar was associated with >4 times the odds of chronic pain (OR = 4.77, p < .001) and hepatitis C (OR = 4.08, p < .001). Likewise, schizophrenia was associated with >4 times the odds of chronic pain (OR = 4.10, p < .001) and hepatitis C (OR = 4.65, p < .001). Additionally, patients with bipolar were >2 times more likely to have eight other severe or chronic conditions (OR range = 2.58—2.05, p’s < .001) compared to controls including acid peptic, asthma, chronic kidney disease, COPD, injury/poisoning and overdose, pneumonia, obesity, and stroke. Patients with schizophrenia were >2 times more likely to have 6 other severe or chronic conditions (OR range = 3.15—2.10, p’s < .001) including acid peptic, COPD, diabetes, pneumonia, obesity, and stroke. Bipolar and schizophrenia were both associated with >1.5 times the odds of four chronic or severe conditions including hypertension, ischemic heart disease, arthritis, and coronary atherosclerosis (Table 3).
Table 3.
Conditional logistic regression models examining associations among patients with serious mental illness and severe or chronic medical conditions compared to controls.
| Chronic Condition Category | Bipolar
|
Schizophrenia
|
||||||
|---|---|---|---|---|---|---|---|---|
|
n = 20,308
|
n = 4,782
|
|||||||
| ORa | 95% CI | SE | pb | ORa | 95% CI | SE | pb | |
| Any Chronic Condition | 2.11 | 2.01, 2.21 | 0.02 | <.001 | 1.77 | 1.61, 1.94 | 0.04 | <.001 |
| Acid-Peptic Disorders | 2.29 | 2.14, 2.45 | 0.03 | <.001 | 2.44 | 2.14, 2.78 | 0.06 | <.001 |
| Arthritis | 1.78 | 1.68, 1.88 | 0.02 | <.001 | 1.15 | 1.03, 1.29 | 0.05 | <.001 |
| Asthma | 2.05 | 1.92, 2.01 | 0.03 | <.001 | 1.79 | 1.57, 2.05 | 0.06 | <.001 |
| Chronic Kidney Disease | 2.41 | 2.14, 2.73 | 0.06 | <.001 | 1.97 | 1.60, 2.43 | 0.10 | <.001 |
| Chronic Pain | 4.77 | 4.33, 5.24 | 0.04 | <.001 | 4.10 | 3.32, 5.05 | 0.10 | <.001 |
| COPD | 2.49 | 2.25, 2.76 | 0.05 | <.001 | 3.15 | 2.60, 3.83 | 0.09 | <.001 |
| Coronary Atherosclerosis | 1.55 | 1.37, 1.76 | 0.06 | <.001 | 1.73 | 1.36, 2.22 | 0.12 | <.001 |
| Diabetes Mellitus | 1.69 | 1.57, 1.83 | 0.03 | <.001 | 2.60 | 2.26, 2.99 | 0.07 | <.001 |
| Hepatitis C | 4.08 | 3.23, 5.15 | 0.11 | <.001 | 4.65 | 2.91, 7.44 | 0.23 | <.001 |
| Hypertension | 1.65 | 1.56, 1.75 | 0.02 | <.001 | 1.80 | 1.62, 2.01 | 0.05 | <.001 |
| Injury, poisoning/overdose | 2.06 | 1.96, 2.16 | 0.02 | <.001 | 1.59 | 1.44, 1.75 | 0.04 | <.001 |
| Ischemic heart disease | 1.54 | 1.36, 1.75 | 0.06 | <.001 | 1.75 | 1.37, 2.25 | 0.12 | <.001 |
| Pneumonia | 2.10 | 1.80, 2.46 | 0.07 | <.001 | 2.10 | 1.57, 2.79 | 0.14 | <.001 |
| Obesity | 2.06 | 1.93, 2.20 | 0.03 | <.001 | 2.84 | 2.46, 3.19 | 0.06 | <.001 |
| Stroke | 2.58 | 2.02, 3.29 | 0.12 | <.001 | 2.96 | 1.82, 4.82 | 0.24 | <.001 |
Note. All conditional logistic regression models adjusted for race/ethnicity and neighborhood income. COPD = chronic obstructive pulmonary disease.
Reference group = Control patients. Patients with bipolar and schizophrenia were matched to control patients, one-to-one on gender, age, and medical home facility.
P-values were adjusted for multiple inference testing using the Hochberg25 method.
DISCUSSION
The high prevalence of medical comorbidities among patients with SMI constitutes major clinical and public health problems that have not been adequately addressed in specialty mental health programs or by mainstream health care.12 This issue is further compounded in individuals who have a SMI by problems associated with substandard living conditions and lack of access to routine health care services, which increase the risk of having unidentified and untreated medical conditions.2,23–24 Lack of preventative health care in combination with high risk health behaviors among individuals with SMI place them at increased risk of several serious and chronic medical conditions.2,4,8,21 Patients with SMI remain at risk for elevated morbidity and mortality, despite that health care reform in the U.S. has increased health care service access for this population in recent years.12 Given the increased likelihood for individuals with SMI to have poor health and poor health outcomes despite policy and clinical intervention, obtaining current information on the degree to which having a SMI is associated with a range of medical comorbidities from large health systems which manage these persons is critical to tailor future disease prevention efforts, early diagnosis, and treatment to their needs.
To inform patient care and service planning, we examined acute and chronic medical conditions in SMI patients in a large integrated health system, where SMI patients potentially may have better access to health services than in health care systems where services are not integrated.27 Prior to our primary analyses, we investigated potential socio-economic differences between controls and SMI patients. Since patients with SMI and the controls were matched by age and gender no differences were anticipated or found regarding these characteristics. Patients with SMI tended to be white relative to controls, except that more patients with schizophrenia were Black. Higher rates of Black patients with schizophrenia is largely consistent with prior research,30–32 and may be in part due to the over-diagnosis of Black persons with this disorder.33 Also consistent with prior work, we found more SMI patients were located in lower-income neighborhood KPNC service areas than controls.12 Prior work has found poor socioeconomic status can dramatically limit access to health care and increase exposure to unhealthy behaviors and lifestyles.2 This phenomenon may partly explain the reason for why having a SMI was disproportionately associated with higher likelihood of having almost all medical comorbidities and serious or chronic conditions examined relative to controls. Notably, while all controls and patients with a SMI had broad access to a range of health services (e.g., primary care, specialty behavioral health services, emergency department, etc.,), lower income for patients with SMI may disproportionately affect their ability to support transportation costs for health system visits and follow-up preventive care, and impact health outcomes. It will be important for future work to more fully examine the role of income in predicting health care access and associated health outcomes in the SMI population. Perhaps in part related to access and low SES, our findings also revealed the odds associated with having acute and chronic medical conditions may not be the same for everyone with a SMI.
Even given differences in study design, types of health care systems and samples studied, our results were largely consistent with prior work that has found patients with schizophrenia are at high risk of having endocrine or immune diseases.2,8,10,13,15,16,34,35 Patients with schizophrenia were more likely to have endocrine or immunity diseases, as well as diabetes and obesity. While we could not address causal relationships (e.g., whether schizophrenia preceded the onset of diabetes or obesity) with our design, the odds associated with having schizophrenia to obesity and diabetes has been linked to the use of some second-generation antipsychotic medications.36,37 This is problematic and concerning, as the long-term use of second-generation antipsychotic medications combined with obesity and adverse lifestyle behavior (i.e., poor diet, smoking, illicit drug use, and physical inactivity) have been linked with higher odds of serious cardiovascular events in patients with schizophrenia and other SMI patient groups.38–40 These phenomena may potentially explain the reason for why we found that having schizophrenia was associated with higher odds of having a serious cardiovascular event, such as stroke. Future longitudinal work in this area is warranted, and will need to focus on isolating predisposing conditions and other risk factors associated with future cardiovascular events and mortality in schizophrenia.
Although far in excess of control patients, the prevalence of cardiovascular disease and predisposing conditions such as diabetes, hypertension, and obesity in our bipolar sample was slightly below prior reports.21 Nevertheless, having bipolar was still associated with higher odds of conditions predisposing cardiovascular disease. Notably, these findings may in part explain the reason for why we also found having bipolar was associated with higher likelihood of serious cardiovascular events, including stroke. These findings are of interest because cardiovascular mortality is a leading cause of elevated mortality in patients with bipolar, and is well above the risk associated with un-natural causes of death such as injury and suicide.21 Consequently, future work in this area is warranted, and will need to determine the risk of cardiovascular disease to future cardiovascular events and cardiovascular mortality in bipolar, as well as whether the rates of cardiovascular mortality may be lower in patients with bipolar in integrated health systems than the general population and other health care systems.
Overall, having bipolar and schizophrenia was associated with high odds of blood borne and infectious disease and of hepatitis C. Although we did not examine routes of transmission, injection drug use, high risk sexual behaviors, or comorbid substance use, SMI patients have been found to exhibit this behavior, raising the odds of blood borne and infectious disease and hepatitis C.43,44 While substantially higher than the control estimates, the prevalence of hepatitis C in our sample fell below previously published rates of hepatitis C in individuals with SMI.44 Hepatitis C and HIV risk are often examined at the same time; yet, we could not estimate HIV risk due to low base rates.
Limitations should be noted. Our SMI sample was comprised of patients with bipolar or schizophrenia, and did not include certain psychiatric disorders sometimes regarded as SMI, such as major depression. While our sample was larger than prior studies of medical comorbidities in SMI, it largely consisted of insured members in an integrated health care system and results may not be generalizable to other SMI populations or other types of health systems. Our use of provider-assigned diagnoses restricted our sample to ICD-9 codes assigned during health plan visits. This method is vulnerable to diagnostic under-estimation;45 and thus, the rates of bipolar and schizophrenia may be somewhat higher than we report. Another potential limitation with the methods used to select the sample is that we required a single mention of an ICD-9 code for SMI during the study period to link the patient with that diagnosis and included all current and existing diagnoses (e.g., could have multiple diagnoses). While this single mention methodology is well established,45–49 it could result in overestimation if diagnoses only mentioned one time in the EHR are more likely to be inaccurate. Since patients with bipolar or schizophrenia could have multiple behavioral diagnoses. Thus, our results should be interpreted with caution until confirmatory studies are conducted in mutually exclusive SMI groups. All data are cross-sectional; and thus, no directionality can be assumed in associations between conditions, and associations do not imply cause-and-effect relationships. Long-term follow-up studies will be required to capture the full impact medical comorbidities have on the course and outcome of individuals with SMI.
The reasons why having SMI is associated with disproportionately high odds of having medical comorbidities are complex and multi-factorial and future studies will need to continue to monitor medical comorbidity in this population as health policies evolve. We found having a SMI was associated with higher odds of having several medical comorbidities as well as chronic and severe medical conditions, even in an integrated health care system where patients have insurance coverage and broad access to care. Our results suggest that that SMI patients have high medical needs, and implementing enhanced outreach efforts focused on prevention, early diagnosis, and treatment of medical comorbidities may help reduce associated morbidity and mortality and improve overall prognosis in this population.
Highlights.
SMI is associated with disproportionately high odds of having several medical comorbidities.
Having a SMI is associated with higher likelihood of chronic and severe medical conditions.
Outreach strategies may be needed to reduce high medical need and poor outcomes in SMI.
Acknowledgments
Funding
This study was supported by the Sidney R. Garfield Memorial Fund and National Institute on Drug Abuse Grant T32DA007250. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIDA.
Appendix A. Substance Use Disorder; Psychiatric and Medical Condition Diagnoses and Internal Classification of Diseases, Ninth Revision Codes
| ICD-9Code | Substance use disorder |
|---|---|
| 291 | Alcohol-induced mental disorders |
| 291.0 | Alcohol withdrawal delirium |
| 291.2 | Alcohol-induced persisting amnestic disorder |
| 291.3 | Alcohol-induced psychotic disorder with hallucinations |
| 291.4 | Idiosyncratic alcohol intoxication |
| 291.5 | Alcohol-induced psychotic disorder with delusions |
| 291.8 | Other specified alcohol-induced mental disorders |
| 291.81 | Alcohol withdrawal |
| 291.82 | Alcohol-induced sleep disorders |
| 291.89 | Other alcohol-induced mental disorders |
| 291.9 | Unspecified alcohol-induced mental disorders |
| 292 | Drug-induced mental disorders |
| 292.0 | Drug withdrawal |
| 292.1 | Drug-induced psychotic disorders |
| 292.11 | Drug-induced psychotic disorder with delusions |
| 292.12 | Drug-induced psychotic disorder with hallucinations |
| 292.2 | Pathological drug intoxication |
| 292.8 | Other specified drug-induced mental disorders |
| 292.81 | Drug-induced delirium |
| 292.82 | Drug-induced persisting dementia |
| 292.83 | Drug-induced persisting amnestic disorder |
| 292.84 | Drug-induced mood disorder |
| 292.85 | Drug-induced sleep disorders |
| 292.89 | Other specified drug-induced mental disorders |
| 292.9 | Unspecified drug-induced mental disorder |
| 303 | Alcohol dependence syndrome |
| 303.0 | Acute alcoholic intoxication |
| 303.00 | Acute intoxication in alcoholism, unspecified |
| 303.01 | Acute intoxication in alcoholism, continuous |
| 303.02 | Acute intoxication in alcoholism, episodic |
| 303.03 | Acute alcoholic intoxication in alcoholism, in remission |
| 303.9 | Other and unspecified alcohol dependence |
| 303.90 | Other and unspecified alcohol dependence, unspecified |
| 303.91 | Other and unspecified alcohol dependence, continuous |
| 303.92 | Other and unspecified alcohol dependence, episodic |
| 303.93 | Other and unspecified alcohol dependence, in remission |
| 304 | Drug dependence |
| 304.0 | Opioid-type dependence |
| 304.00 | Opioid-type dependence, unspecified |
| 304.01 | Opioid-type dependence, continuous |
| 304.02 | Opioid-type dependence, episodic |
| 304.03 | Opioid-type dependence, in remission |
| 304.1 | Sedative, hypnotic or anxiolytic dependence |
| 304.10 | Sedative, hypnotic or anxiolytic dependence, unspecified |
| 304.11 | Sedative, hypnotic or anxiolytic dependence, continuous |
| 304.12 | Sedative, hypnotic or anxiolytic dependence, episodic |
| 304.13 | Sedative, hypnotic or anxiolytic dependence, in remission |
| 304.2 | Cocaine dependence |
| 304.20 | Cocaine dependence, unspecified |
| 304.21 | Cocaine dependence, continuous |
| 304.22 | Cocaine dependence, episodic |
| 304.23 | Cocaine dependence, in remission |
| 304.3 | Cannabis dependence |
| 304.30 | Cannabis dependence, unspecified |
| 304.31 | Cannabis dependence, continuous |
| 304.32 | Cannabis dependence, episodic |
| 304.33 | Cannabis dependence, in remission |
| 304.4 | Amphetamine and other psychostimulant dependence |
| 304.40 | Amphetamine and other psychostimulant dependence, unspecified |
| 304.41 | Amphetamine and other psychostimulant dependence, continuous |
| 304.42 | Amphetamine and other psychostimulant dependence, episodic |
| 304.43 | Amphetamine and other psychostimulant dependence, in remission |
| 304.5 | Hallucinogen dependence |
| 304.50 | Hallucinogen dependence, unspecified |
| 304.51 | Hallucinogen dependence, continuous |
| 304.52 | Hallucinogen dependence, episodic |
| 304.53 | Hallucinogen dependence, in remission |
| 304.6 | Other specified drug dependence |
| 304.60 | Other specified drug dependence, unspecified |
| 304.61 | Other specified drug dependence, continuous |
| 304.62 | Other specified drug dependence, episodic |
| 304.63 | Other specified drug dependence, in remission |
| 304.7 | Combinations of opioid-type drug with any other drug dependence |
| 304.70 | Combinations of opioid-type drug with any other drug dependence, unspecified |
| 304.71 | Combinations of opioid-type drug with any other drug dependence, continuous |
| 304.72 | Combinations of opioid-type drug with any other drug dependence, episodic |
| 304.73 | Combinations of opioid-type drug with any other drug dependence, in remission |
| 304.8 | Combinations of drug dependence excluding opioid-type drug |
| 304.80 | Combinations of drug dependence excluding opioid-type drug, unspecified |
| 304.81 | Combinations of drug dependence excluding opioid-type drug, continuous |
| 304.82 | Combinations of drug dependence excluding opioid-type drug, episodic |
| 304.83 | Combinations of drug dependence excluding opioid-type drug, in remission |
| 304.9 | Unspecified drug dependence |
| 304.90 | Unspecified drug dependence, unspecified |
| 304.91 | Unspecified drug dependence, continuous |
| 304.92 | Unspecified drug dependence, episodic |
| 304.93 | Unspecified drug dependence, in remission |
| 305 | Nondependent abuse of drugs |
| 305.0 | Nondependent alcohol abuse |
| 305.00 | Alcohol abuse, unspecified |
| 305.01 | Alcohol abuse, continuous |
| 305.02 | Alcohol abuse, episodic |
| 305.03 | Alcohol abuse, in remission |
| 305.2 | Nondependent cannabis abuse |
| 305.20 | Cannabis abuse, unspecified |
| 305.21 | Cannabis abuse, continuous |
| 305.22 | Cannabis abuse, episodic |
| 305.23 | Cannabis abuse, in remission |
| 305.3 | Nondependent hallucinogen abuse |
| 305.30 | Hallucinogen abuse, unspecified |
| 305.31 | Hallucinogen abuse, continuous |
| 305.32 | Hallucinogen abuse, episodic |
| 305.33 | Hallucinogen abuse, in remission |
| 305.4 | Nondependent sedative, hypnotic or anxiolytic abuse |
| 305.40 | Sedative, hypnotic or anxiolytic abuse, unspecified |
| 305.41 | Sedative, hypnotic or anxiolytic abuse, continuous |
| 305.42 | Sedative, hypnotic or anxiolytic abuse, episodic |
| 305.43 | Sedative, hypnotic or anxiolytic abuse, in remission |
| 305.5 | Nondependent opioid abuse |
| 305.50 | Opioid abuse, unspecified |
| 305.51 | Opioid abuse, continuous |
| 305.52 | Opioid abuse, episodic |
| 305.53 | Opioid abuse, in remission |
| 305.6 | Nondependent cocaine abuse |
| 305.60 | Cocaine abuse, unspecified |
| 305.61 | Cocaine abuse, continuous |
| 305.62 | Cocaine abuse, episodic |
| 305.63 | Cocaine abuse, in remission |
| 305.7 | Nondependent amphetamine or related acting sympathomimetic abuse |
| 305.71 | Amphetamine or related acting sympathomimetic abuse, unspecified |
| 305.72 | Amphetamine or related acting sympathomimetic abuse, continuous |
| 305.73 | Amphetamine or related acting sympathomimetic abuse, episodic |
| 305.8 | Nondependent antidepressant-type abuse |
| 305.80 | Antidepressant-type abuse, unspecified |
| 305.82 | Antidepressant-type abuse, continuous |
| 305.83 | Antidepressant-type abuse, episodic |
| 305.9 | Nondependent other mixed or unspecified drug abuse |
| 305.90 | Other, mixed, or unspecified drug abuse, unspecified |
| 305.91 | Other, mixed, or unspecified drug abuse, continuous |
| 305.92 | Other, mixed, or unspecified drug abuse, episodic |
| 305.93 | Other, mixed, or unspecified drug abuse, in remission |
|
| |
| ICD-9 Code | Medical Condition |
|
| |
| 530–534 | Acid-peptic disorders |
| 710–719 | Arthritis |
| 493 | Asthma |
| 585.9, 403, or 585.1–585.5 | Chronic kidney disease |
| 490–492 | Chronic obstructive pulmonary disease |
| 338.2 | Chronic pain |
| 402.01, 402.11, 402.91, 404.01, 404.11, or 428 | Congestive heart failure |
| 440, 429.2, 410–414 | Coronary Atherosclerosis |
| 250 | Diabetes mellitus |
| 585.6 | End-stage renal disease |
| 339, 784.0, or 346 | Headaches |
| 0.07.70, 080.74, or 070.75 | Hepatitis C |
| 401–405 | Hypertension |
| 800–999 | Injuries, poisonings, and overdoses |
| 410–414 | Ischemic heart disease |
| 278 | Obesity |
| 733.3 | Osteoporosis |
| 770, 480–486 | Pneumonia |
| 345 | Stroke |
|
| |
| ICD-9 Code | Psychiatric Condition |
|
| |
| 300.00 | Anxiety disorder NOS |
| 300.01 | Panic disorder without agoraphobia |
| 300.02 | Generalized anxiety disorder |
| 300.2 | Phobia, unspecified |
| 300.21 | Panic disorder with agoraphobia |
| 300.22 | Agoraphobia without history of panic disorder |
| 300.23 | Social phobia (social anxiety) |
| 300.29 | Specific phobia |
| 300.3 | Obsessive compulsive disorder |
| 309.20 | Adjustment disorders with anxiety |
| 309.21 | Separation anxiety disorder |
| 309.24 | Adjustment disorder with anxiety |
| 309.81 | Posttraumatic stress disorder |
| 308.3 | Acute stress disorder |
| 314.00 | Attention deficit disorder, inattentive type |
| 314.01 | Attention deficit disorder, hyperactive/impulsive or combined type |
| 314.1 | Hyperkinesis with developmental delay |
| 314.2 | Hyperkinetic conduct disorder of childhood |
| 314.8 | Other specific manifests hyperkinetic syndrome, child |
| 314.9 | Attention deficit disorder NOS |
| 299.01 | Autistic disorder, residual state |
| 299.10 | Childhood disintegrative disorder |
| 299.11 | Childhood disintegrative disorder, residual state |
| 299.80 | Asperger’s disorder/pervasive developmental disorder |
| 299.00 | Autistic disorder, current or active state |
| 296.00 | Bipolar I disorder, single manic episode, unspecified |
| 296.01 | Bipolar I disorder, single manic episode, mild |
| 296.02 | Bipolar I disorder, single manic episode, moderate |
| 296.03 | Bipolar I disorder, single manic episode, severe without psychosis |
| 296.04 | Bipolar I disorder, single manic episode, severe with psychosis |
| 206.05 | Bipolar I disorder, single manic episode, in partial remission |
| 296.06 | Bipolar I disorder, single manic episode, in full remission |
| 296.1 | Manic recurrent episode |
| 296.10 | Manic disorder recurrent episode unspecified |
| 296.11 | Recurrent manic disorder, mild |
| 296.12 | Recurrent manic disorder, moderate |
| 296.13 | Recurrent manic disorder, severe |
| 296.14 | Manic affective disorder, recurrent episode, severe, specified as with psychotic behavior |
| 296.15 | Manic affective disorder, recurrent episode, in partial or unspecified remission |
| 296.16 | Recurrent manic disorder, full remission |
| 296.40 | Bipolar I disorder, most recent episode manic, unspecified |
| 296.41 | Bipolar I disorder, most recent episode manic, mild |
| 296.42 | Bipolar I disorder, most recent episode manic, moderate |
| 296.43 | Bipolar I disorder, most recent episode manic, severe without psychosis |
| 296.44 | Bipolar I disorder, most recent episode manic, severe with psychosis |
| 296.45 | Bipolar I disorder, most recent episode manic, in partial remission |
| 296.46 | Bipolar I disorder, most recent episode manic, in full remission |
| 296.50 | Bipolar I disorder, most recent episode depressed, unspecified |
| 296.51 | Bipolar I disorder, most recent episode depressed, mild |
| 296.52 | Bipolar I disorder, most recent episode depressed, moderate |
| 296.53 | Bipolar I disorder, most recent episode depressed, severe without psychosis |
| 296.54 | Bipolar I disorder, most recent episode depressed, severe with psychosis |
| 296.55 | Bipolar I disorder, most recent episode depressed in partial remission |
| 296.56 | Bipolar I disorder, most recent episode depressed, in full remission |
| 296.60 | Bipolar I disorder, most recent episode mixed, unspecified |
| 296.61 | Bipolar I disorder, most recent episode mixed, mild |
| 296.62 | Bipolar I disorder, most recent episode mixed, moderate |
| 296.63 | Bipolar I disorder, most recent episode mixed, severe without psychosis |
| 296.64 | Bipolar I disorder, most recent episode mixed, severe in partial remission |
| 296.65 | Bipolar I disorder, most recent episode mixed, in partial remission |
| 296.66 | Bipolar I disorder, most recent episode mixed, in full remission |
| 296.7 | Bipolar I disorder, most recent episode unspecified |
| 296.80 | Bipolar disorder NOS |
| 296.81 | Atypical manic disorder |
| 296.89 | Bipolar II disorder |
| 301.11 | Chronic hypomanic disorder |
| 301.13 | Cyclothymic disorder |
| 296.2 | Major depression, single episode, unspecified |
| 296.20 | Major depression, single episode, unspecified |
| 296.21 | Major depression, single episode, mild |
| 296.22 | Major depression, single episode, moderate |
| 296.23 | Major depression, single episode, severe without psychosis |
| 296.24 | Major depression, single episode, severe with psychosis |
| 296.25 | Major depression, single episode, in partial remission |
| 296.26 | Major depression, single episode, in partial remission |
| 296.3 | Major depression, recurrent, unspecified |
| 296.30 | Major depression, recurrent, unspecified |
| 296.31 | Major depression, recurrent, mild |
| 296.32 | Major depression, recurrent, moderate |
| 296.33 | Major depression, recurrent, severe without psychosis |
| 296.34 | Major depression, recurrent, severe with psychosis |
| 296.35 | Major depression, recurrent, in partial remission |
| 296.36 | Major depression, recurrent, in full remission |
| 296.82 | Atypical depressive disorder |
| 298.0 | Depressive-type psychosis |
| 300.4 | Dysthymia |
| 301.12 | Chronic depressive personality disorder |
| 311 | Depressive disorder NOS |
| 309.0 | Adjustment disorder with depressed mood |
| 309.1 | Prolonged depressive reaction |
| 309.28 | Adjustment disorder with mixed anxiety and depressed mood |
| 297.1 | Delusional disorder |
| 297.3 | Shared psychotic disorder |
| 298.8 | Brief psychotic disorder |
| 298.9 | Psychotic disorder NOS |
| 310.0 | Paranoid personality disorder |
| 301.1 | Affective personality disorder, unspecified |
| 301.11 | Chronic hypomanic personality disorder |
| 301.12 | Chronic depressive personality disorder |
| 301.13 | Cyclothymic disorder |
| 301.2 | Schizoid personality disorder |
| 301.20 | Schizoid personality disorder |
| 301.3 | Explosive |
| 301.4 | Obsessive compulsive personality disorder |
| 301.5 | Histrionic personality disorder |
| 301.50 | Histrionic personality disorder, unspecified |
| 301.51 | Chronic factitious illness with physical symptoms |
| 301.52 | Other histrionic personality disorder |
| 301.6 | Dependent personality disorder |
| 301.7 | Antisocial personality disorder |
| 301.8 | Other personality disorder |
| 301.81 | Narcissistic personality disorder |
| 301.82 | Avoidant personality disorder |
| 301.83 | Borderline personality disorder |
| 301.84 | Passive-aggressive personality |
| 301.89 | Other personality disorders |
| 301.9 | Unspecified personality disorder |
| 295.0 | Simple-type schizophrenia |
| 295.00 | Simple-type schizophrenia, unspecified |
| 295.01 | Simple-type schizophrenia, subchronic |
| 295.02 | Simple-type schizophrenia, chronic |
| 295.03 | Simple-type schizophrenia, subchronic with acute exacerbation |
| 295.04 | Simple-type schizophrenia, chronic with acute exacerbation |
| 295.05 | Simple-type schizophrenia, in remission |
| 295.1 | Disorganized-type schizophrenia, unspecified |
| 295.11 | Disorganized-type schizophrenia, subchronic |
| 295.12 | Disorganized-type schizophrenia, chronic |
| 295.13 | Disorganized-type schizophrenia, subchronic with acute exacerbation |
| 295.14 | Disorganized-type schizophrenia, chronic with acute exacerbation |
| 295.15 | Disorganized-type schizophrenia, in remission |
| 295.2* | Catatonic-type schizophrenia |
| 295.20 | Catatonic type schizophrenia, unspecified |
| 295.21 | Catatonic type schizophrenia, subchronic |
| 295.22 | Catatonic type schizophrenia, chronic |
| 295.23 | Catatonic-type schizophrenia, subchronic with acute exacerbation |
| 295.24 | Catatonic-type schizophrenia, chronic with acute exacerbation |
| 295.25 | Catatonic-type schizophrenia, in remission |
| 295.3 | Schizophrenia, paranoid type |
| 295.30 | Paranoid-type schizophrenia, unspecified |
| 295.32 | Paranoid-type schizophrenia, subchronic |
| 295.33 | Paranoid-type schizophrenia, chronic |
| 295.34 | Paranoid-type schizophrenia, subchronic with acute exacerbation |
| 295.35 | Paranoid-type schizophrenia, in remission |
| 295.4 | Schizophreniform disorder |
| 295.40 | Schizophreniform disorder, unspecified |
| 295.41 | Schizophreniform disorder, subchronic |
| 295.42 | Schizophreniform disorder, chronic |
| 295.43 | Schizophreniform disorder, subchronic with acute exacerbation |
| 295.44 | Schizophreniform disorder, chronic with acute exacerbation |
| 295.45 | Schizophreniform disorder, in remission |
| 295.5 | Latent schizophrenia |
| 295.50 | Latent schizophrenia, unspecified |
| 295.51 | Latent schizophrenia, subchronic |
| 295.52 | Latent schizophrenia, chronic |
| 295.53 | Latent schizophrenia, subchronic with acute exacerbation |
| 295.54 | Latent schizophrenia, in remission |
| 295.55 | Latent schizophrenia, in remission |
| 295.6* | Schizophrenia, residual type |
| 295.60 | Schizophrenic disorders, residual type, unspecified |
| 295.61 | Schizophrenic disorders, residual type, subchronic |
| 295.62 | Schizophrenic disorders, residual type, chronic |
| 295.63 | Schizophrenic disorders, residual type, subchronic with acute exacerbation |
| 295.64 | Schizophrenic disorders, residual type, chronic with acute exacerbation |
| 295.65 | Schizophrenic disorders, residual type, in remission |
| 295.7 | Schizoaffective disorder |
| 295.70 | Schizoaffective disorder, unspecified |
| 295.71 | Schizoaffective disorder, subchronic |
| 295.72 | Schizoaffective disorder, chronic |
| 295.73 | Schizoaffective disorder, subchronic with acute exacerbation |
| 295.74 | Schizoaffective disorder, chronic with acute exacerbation |
| 295.75 | Schizoaffective disorder, in remission |
| 295.8 | Other specified types of schizophrenia |
| 295.80 | Other specified types of schizophrenia, unspecified |
| 295.81 | Other specified types of schizophrenia, subchronic |
| 295.82 | Other specified types of schizophrenia, chronic |
| 295.83 | Other specified types of schizophrenia, subchronic with acute exacerbation |
| 295.84 | Other specified types of schizophrenia, chronic with acute exacerbation |
| 295.85 | Other unspecified types of schizophrenia, in remission |
| 295.9 | Unspecified schizophrenia |
| 295.90 | Unspecified schizophrenia, unspecified |
| 295.91 | Unspecified schizophrenia, subchronic |
| 295.92 | Unspecified schizophrenia, chronic |
| 295.93 | Unspecified schizophrenia, subchronic with acute exacerbation |
| 295.94 | Unspecified schizophrenia, chronic with acute exacerbation |
| 295.95 | Unspecified schizophrenia in remission |
Footnotes
Conflicts of Interest
None of the authors reported a conflict of interest with respect to this project.
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