Associations between Social Adversities and Chronic Medical Conditions in a Statewide Sample of Individuals in Treatment for Mental Illnesses.

Individuals with mental illnesses experience disproportionately high rates of social adversities, chronic medical conditions, and early mortality. We analyzed a large, statewide dataset to explore associations between four social adversities and the presence of one or more, and then two or more, chronic medical conditions among individuals in treatment for mental illnesses in New York State. In Poisson regression models adjusting for multiple covariates (e.g., gender, age, smoking status, alcohol use), the presence of one or more adversities was associated with the presence of at least one medical condition (prevalence ratio (PR) = 1.21) or two or more medical conditions (PR = 1.46), and two or more adversities was associated with at least one medical condition (PR = 1.25) or two or more medical conditions (PR = 1.52) (all significant at p < .0001). Greater attention to primary, secondary, and tertiary prevention of chronic medical conditions is needed in mental health treatment settings, especially among those experiencing social adversities.

Introducing the Staff-Administered Meal Independence Rating Scale for Use Among Patients With Serious Mental Illnesses.

ABSTRACT: For individuals living with serious mental illnesses (SMIs), inadequate meal preparation skills can hinder the ability to live independently; yet rating scales tailored for this population are lacking. We describe development, item analysis, and initial reliability and validity of the Staff-Administered Meal Independence Rating Scale (SAMIRS). After item development involving expert consultation, two rounds of pilot testing ( n = 188, n = 293) were conducted in inpatient and residential settings (transitional living residences [TLRs] and community residences [CRs]). For initial testing of convergent validity, Pearson correlations with Specific Levels of Functioning (SLOF) scale items were computed. Exploratory factor analysis revealed a single factor; Cronbach's alpha was high (0.98). The mean SAMIRS score varied by setting: CR residents scored higher than those in TLRs or inpatient units. Scores were highly correlated with SLOF items measuring community living skills. Although further study is warranted, the SAMIRS could be a useful tool in rating functional needs pertaining to meal independence among individuals with SMI.

Disparities in COVID-19-Related Psychological Distress Among Recipients of a State's Public Mental Health Services.

OBJECTIVE: The authors examined changes in perceived anxiety, stress, and mental health symptoms (i.e., psychological distress) reported by recipients of New York State public mental health services during the early months of the COVID-19 pandemic, as well as whether these changes varied by demographic characteristics or pandemic-related socioeconomic challenges. METHODS: A statewide survey of service recipients (N=3,483) was conducted (May 8-June 22, 2020). Descriptive analyses were summarized, and logistic regression was used to evaluate associations between increases in reported psychological distress and age, gender, region of residence, race and ethnicity, socioeconomic challenges, and alcohol or drug use. RESULTS: Fifty-five percent of respondents (N=1,933) reported a slight or moderate increase in COVID-19-related psychological distress, and 15% (N=520) reported a substantial increase. In adjusted models, substantial elevations in psychological distress were associated with identifying as female (AOR=1.83, 95% CI=1.50-2.25), experiencing three or more pandemic-related socioeconomic challenges (AOR=2.41, 95% CI=1.91-3.03), and reporting increased use of alcohol or drugs (AOR=1.81, 95% CI=1.34-2.44). Compared with non-Hispanic/Latinx White service recipients, non-Hispanic/Latinx Black individuals had lower odds of reporting substantially increased psychological distress (AOR=0.59, 95% CI=0.45-0.76), as did non-Hispanic/Latinx Asian-descent individuals (AOR=0.28, 95% CI=0.12-0.64). CONCLUSIONS: In this large sample of recipients of New York State public mental health services, the COVID-19 pandemic's impact on psychological well-being was widespread and varied by gender, race and ethnicity, and socioeconomic vulnerability. These relationships must be considered in ongoing efforts to provide optimal care for this population.

Associations Between Cumulative Social Adversities and Substance Use Comorbidity in a Statewide Sample of Individuals in Treatment for Mental Illnesses.

ABSTRACT: We sought to investigate associations of cumulative social adversities in four areas (low education, unemployment, homelessness, and criminal/legal involvement) with presence of comorbid alcohol and drug use disorders among individuals in treatment for mental illnesses. Using data from 103,416 adults in mental health treatment, generalized estimating equation modified Poisson models were used to estimate increased risk of having comorbid substance use disorders based on individual and/or cumulative number of social adversities present. Controlling for effects of sex, race/ethnicity, and region (New York City vs . the rest of the State), as well as for the other social adversities, each of four social adversities was associated with presence of substance use comorbidity. Relative to having none of the social adversities, the presence of one, two, three, or four was associated with an increased prevalence ratio (PR) of having substance use comorbidity: 1.44, 2.10, 2.66, and 2.92; all p 's < 0.0001. PRs were greater among female patients, and among Hispanics and those classified as other or multiracial compared with non-Hispanic Whites or non-Hispanic Blacks. Findings indicate substantial associations between four social adversities and presence of substance use comorbidity; the strength of association with the four social adversities is cumulative.

The association between reproductive rights and access to abortion services and mental health among US women.

Background: This study examines whether living in US states with (1) restrictive reproductive rights and (2) restrictive abortion laws is associated with frequent mental health distress among women. Methods: We operationalize reproductive rights using an overall state-level measure of reproductive rights as well as a state-level measure of restrictive abortion laws. We merged data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) with these state-level exposure variables and other state-level information. We used multilevel logistic regression to assess the relationship between these two measures and the likelihood of reporting 14 or more days of frequent mental health distress. We also tested whether associations differed across race, household income, education, and marital status. Results: In the adjusted models, a standard deviation-unit increase in the reproductive rights score was significantly associated with decreased odds of reporting frequent mental health distress (OR = 0.95, 95% CI = 0.91, 0.99). Women in states with very hostile abortion restrictions had higher odds of frequent mental health distress. Associations between state-level abortion restrictions were larger among women 25-34 years old and women with a high school degree. For example, women aged 25-34 years residing in moderate (OR = 1.54, 95% CI = 1.14, 2.04), hostile (OR = 1.59, 95% CI = 1.15, 2.18), and very hostile (OR = 1.29, 95% CI = 1.02, 1.64) states were more likely to report frequent mental health distress than women living in states with less restrictive abortion policies. Conclusion: We found the association between state-level restrictions on reproductive rights and abortion access and frequent mental health distress differed by age and socioeconomic status. These results suggest abortion rights restrictions may contribute to mental health inequities among women.

Prevalence and Correlates of Four Social Determinants in a Statewide Survey of Licensed Mental Health Services.

OBJECTIVE: This analysis examined the distribution of four social determinants of health among recipients of state-licensed mental health services and analyzed relationships between determinants and individuals' clinical and demographic characteristics. METHODS: With data from the New York State Office of Mental Health 2017 Patient Characteristics Survey (N=103,416), prevalences of four social determinants (education, employment, housing, and criminal legal involvement) among mental health service recipients were described. Results were stratified to explore differences by diagnosis, gender, race and ethnicity, and region of residence. RESULTS: High proportions had low education (20.9%), unemployment (79.1%), homelessness (8.2%), and criminal legal involvement (12.2%), surpassing statistics for the general state population. Prevalences of alcohol-related, drug-related, and psychotic disorders were higher among these groups than were prevalences of other diagnoses. People of color and male recipients were overrepresented among those with adverse social determinants. CONCLUSIONS: Results highlight the magnitude of social adversity among those receiving mental health services, as well as potential inequities.

The Social Determinants of Mental Health: A Descriptive Study of State Mental Health Agencies' Priorities.

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals' physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.

The Impacts of COVID-19 on a Statewide Population With Mental Illness.

OBJECTIVE: This survey examined the experiences of individuals receiving treatment in a large public mental health system during the early months of the COVID-19 pandemic. METHODS: The survey, conducted between May and June 2020, assessed four domains: impacts on mental health, experiences with telehealth, access to care and resources, and sources and adequacy of support. Descriptive analyses were conducted. RESULTS: Of 4,046 respondents, 70% reported increases in their anxiety and stress because of the pandemic. A majority (55%) reported experiencing challenges related to the social determinants of health and functional needs. Most respondents reported that their care went undisrupted, with 92% using telehealth and 90% reporting feeling adequately supported. CONCLUSIONS: The pandemic substantially affected individuals with mental illness, particularly with regard to mental health related to the social determinants of health and functional needs. However, respondents felt that their mental health care was maintained and that they were adequately supported.

Race, Adolescent Socioeconomic Status, and Lifetime Non-Medical Use of Prescription Painkillers: Evidence from the National Longitudinal Study of Adolescent to Adult Health.

The misuse of prescription painkillers is a major contributor to the ongoing drug overdose epidemic. This study investigated variability in non-medical use of prescription painkillers (NMUPP) by race and early-life socioeconomic status (SES) in a sample now at increased risk for opioid overdose. Data from two waves of the National Longitudinal Study of Adolescent to Adult Health (n = 11,602) were used to calculate prevalence of reported NMUPP by Wave 4 (2008; mean age 28), and to assess variation by race and by equivalized household family income at Wave 1 (1994/5). Predicted values for prevalence of NMUPP were modelled, adjusting for age, sex, parental education, and region. Race and SES in adolescence were associated with later reported NMUPP. A gradient was seen in prevalence by SES (adjusted: family income quartile 1 = 13.3%; quartile 2 = 13.8%; quartile 3 = 14.8%; quartile 4 = 16.0%; trend p-value = 0.007). Prevalence was higher among males. Racial/ethnic differences in prevalence were seen (non-Hispanic white (NHW) = 18.5%; non-Hispanic black (NHB) = 5.8%; Hispanic = 10.5%; Other = 10.0%). SES differences were less pronounced upon stratification, with trend tests significant only among females (p = 0.004), and marginally significant among Hispanic males (p = 0.06). Early-life SES was associated with reported lifetime NMUPP: the higher the family income in adolescence, the greater the likelihood of NMUPP by young adulthood. Variations in NMUPP by income paled in comparison with racial/ethnic differences. Results point to a possible long-enduring association between SES and NMUPP, and a need to examine underlying mechanisms.

State- and county-level income inequality and infant mortality in the USA in 2010: a cohort study.

OBJECTIVES: We examined the relationship between income inequality and the risk for infant/neonatal mortality at the state and county level and tested possible mediators of this relationship. METHODS: We first linked state and county Gini coefficients to US Vital Statistics 2010 Cohort Linked Birth and Infant Death records (n = 3,954,325). We then fit multilevel models to test whether income inequality was associated with infant/neonatal mortality. County-level factors were tested as potential mediators. RESULTS: Adjusted analyses indicated that income inequality at the county level-but not at the state level-was associated with increased odds of infant mortality (OR 1.14, 95% CI 1.10, 1.18) and neonatal death (OR 1.17, 95% CI 1.12, 1.23). Our mediators explained most of this variation. Bivariate analyses revealed associations between 3 county-level measures-patient-to-physician ratio, the violent crime rate, and sexually transmitted infection rate-and infant and neonatal mortality. Proportion of college-educated adults was associated with decreased odds for neonatal mortality. CONCLUSIONS: Local variations in access to care, the rate of sexually transmitted disease, and crime are associated with infant mortality, while variations in college education in addition to these mediators explain neonatal mortality. To reduce infant and neonatal mortality, experiments are needed to examine the effectiveness of policies targeted at reducing income inequality and improving healthcare access, policing, and educational opportunities.

Laws Restricting Access to Abortion Services and Infant Mortality Risk in the United States.

OBJECTIVES: Since the US Supreme Court's 1973 Roe v. Wade decision legalizing abortion, states have enacted laws restricting access to abortion services. Previous studies suggest that restricting access to abortion is a risk factor for adverse maternal and infant health. The objective of this investigation is to study the relationship between the type and the number of state-level restrictive abortion laws and infant mortality risk. METHODS: We used data on 11,972,629 infants and mothers from the US Cohort Linked Birth/Infant Death Data Files 2008-2010. State-level abortion laws included Medicaid funding restrictions, mandatory parental involvement, mandatory counseling, mandatory waiting period, and two-visit laws. Multilevel logistic regression was used to determine whether type or number of state-level restrictive abortion laws during year of birth were associated with odds of infant mortality. RESULTS: Compared to infants living in states with no restrictive laws, infants living in states with one or two restrictive laws (adjusted odds ratio (AOR) = 1.08; 95% confidence interval [CI] = 0.99-1.18) and those living in states with 3 to 5 restrictive laws (AOR = 1.10; 95% CI = 1.01-1.20) were more likely to die. Separate analyses examining the relationship between parental involvement laws and infant mortality risk, stratified by maternal age, indicated that significant associations were observed among mothers aged ≤19 years (AOR = 1.09, 95% CI = 1.00-1.19), and 20 to 25 years (AOR = 1.10, 95% CI = 1.03-1.17). No significant association was observed among infants born to older mothers. CONCLUSION: Restricting access to abortion services may increase the risk for infant mortality.

Differential relationship between state-level minimum wage and infant mortality risk among US infants born to white and black mothers.

BACKGROUND: Compared to other Organisation for Economic Co-operation and Development (OECD) nations, US infant mortality rates (IMRs) are particularly high. These differences are partially driven by racial disparities, with non-Hispanic black having IMRs that are twice those of non-Hispanic white. Income inequality (the gap between rich and poor) is associated with infant mortality. One proposed way to decrease income inequality (and possibly to improve birth outcomes) is to increase the minimum wage. We aimed to elucidate the relationship between state-level minimum wage and infant mortality risk using individual-level and state-level data. We also determined whether observed associations were heterogeneous across racial groups. METHODS: Data were from US Vital Statistics 2010 Cohort Linked Birth and Infant Death records and the 2010 US Bureau of Labor Statistics. We fit multilevel logistic models to test whether state minimum wage was associated with infant mortality. Minimum wage was standardised using the z-transformation and was dichotomised (high vs low) at the 75th percentile. Analyses were stratified by mother's race (non-Hispanic black vs non-Hispanic white). RESULTS: High minimum wage (adjusted OR (AOR)=0.93, 95% CI 0.83 to 1.03) was associated with decreased odds of infant mortality but was not statistically significant. High minimum wage was significantly associated with reduced infant mortality among non-Hispanic black infants (AOR=0.80, 95% CI 0.68 to 0.94) but not among non-Hispanic white infants (AOR=1.04, 95% CI 0.92 to 1.17). CONCLUSIONS: Increasing the minimum wage might be beneficial to infant health, especially among non-Hispanic black infants, and thus might decrease the racial disparity in infant mortality.

Structural Racism and Odds for Infant Mortality Among Infants Born in the United States 2010.

OBJECTIVES: While ecological studies indicate that high levels of structural racism within US states are associated with elevated infant mortality rates, studies using individual-level data are needed. To determine whether indicators of structural racism are associated with the individual odds for infant mortality among white and black infants in the US. METHODS: We used data on 2,163,096 white and 590,081 black infants from the 2010 US Cohort Linked Birth/Infant Death Data Files. Structural racism indicators were ratios of relative proportions of blacks to whites for these domains: electoral (registered to vote and voted; state legislature representation), employment (civilian labor force; employed; in management; with a bachelor's degree), and justice system (sentenced to death; incarcerated). Multilevel logistic regression was used to determine whether structural racism indicators were risk factors of infant mortality. RESULTS: Compared to the lowest tertile ratio of relative proportions of blacks to whites with a bachelor's degree or higher-indicative of low structural racism-black infants, but not whites, in states with moderate (OR = 1.12, 95% CI = 0.94, 1.32) and high tertiles (OR = 1.25, 95% CI = 1.03, 1.51) had higher odds of infant mortality. CONCLUSIONS: Educational and judicial indicators of structural racism were associated with infant mortality among blacks. Decreasing structural racism could prevent black infant deaths.

Novel use of syndromic surveillance to monitor the impact of synthetic cannabinoid control measures on morbidity.

BACKGROUND: Using data from syndromic surveillance, the New York City Department of Health and Mental Hygiene (DOHMH) identified an increase in the number of emergency department (ED) visits related to synthetic cannabinoids. Syndromic surveillance data were used to target community-level interventions and assess the real-time impact of control measures in reducing synthetic cannabinoid ("K2")-related morbidity. METHODS: From April 2015 through September 2015, DOHMH implemented 3 separate interventions to reduce K2-related morbidity by limiting the availability of K2 products. Difference-in-difference analyses compared pre- and post-intervention differences in cannabinoid-related ED visit rates between neighborhoods and controls for Interventions A and B. City-wide count data were used to compare K2-related ED visits before and after Intervention C. RESULTS: Syndromic data showed a reduction in K2-related ED visits following the 3 interventions. Respective decreases in rates of synthetic cannabinoid-related ED visits of 33 and 38% were detected at the neighborhood-level due to Interventions A and B, respectively. A decrease of 29% was calculated at the city level following Intervention C. CONCLUSIONS: In addition to identifying emerging public health concerns, syndromic data can provide valuable real-time evidence on the effectiveness of public health interventions.

School racial composition and lifetime non-medical use of prescription painkillers: Evidence from the national longitudinal study of adolescent to adult health.

OBJECTIVE: To investigate the possible effects of middle and high school racial composition on later reporting of lifetime non-medical use of prescription painkillers (NMUPP) in young adulthood, and to explore whether there is evidence of variability by individual race/ethnicity in such effects. METHODS: Using data from Wave 1 (1994/5) of the National Longitudinal Study of Adolescent to Adult Health (Add Health), we categorized the sample's 52 middle schools and 80 high schools as majority (>50%) non-Hispanic white, majority non-Hispanic black, or neither. We used two-level hierarchical modeling to explore associations between individual- and school-level race at Wave 1 and lifetime prescription painkiller misuse reported at Wave 4. We included a cross-level interaction between individual race and school racial composition to assess variability in school-level associations by race. RESULTS: Overall crude prevalence of lifetime NMUPP in majority white schools (17.9%) was over three times that of prevalence in majority black schools (4.8%), and also higher than prevalence in schools neither predominantly black nor predominantly white (12.4%). Lifetime misuse among blacks in majority white schools was more prevalent (5.2%) than among blacks in black schools (2.8%), as was misuse among whites in white schools (19.3%) compared to their white peers in black schools (15.7%). Two-level random intercept Poisson regression results suggest that attendance in a majority black secondary school lowered a participant's risk of lifetime NMUPP (compared to attending a majority white school: RR=0.66, p = 0.03). Compared to blacks in black schools, blacks in white schools had twice the risk of prescription painkiller misuse (p = 0.004) over a decade later, and whites in white schools had 5.5 times the risk (p = 0.01). The risk ratio comparing whites in black schools to whites in white schools was not significant (RR: 1.30; p = 0.37). CONCLUSIONS: We found evidence of an effect of school racial composition on the risk of misusing prescription painkillers over a decade later, over and above individual race, with higher risk of misuse reported among participants who had attended white schools. Black participants who had attended predominantly white schools were, on average, twice as likely to report lifetime misuse of prescription painkillers compared to blacks who had attended black schools.

Neighborhood Differences in Post-Stroke Mortality.

BACKGROUND: Post-stroke mortality is higher among residents of disadvantaged neighborhoods, but it is not known whether neighborhood inequalities are specific to stroke survival or similar to mortality patterns in the general population. We hypothesized that neighborhood disadvantage would predict higher poststroke mortality, and neighborhood effects would be relatively larger for stroke patients than for individuals with no history of stroke. METHODS AND RESULTS: Health and Retirement Study participants aged ≥50 years without stroke at baseline (n=15 560) were followed ≤12 years for incident stroke (1715 events over 159 286 person-years) and mortality (5325 deaths). Baseline neighborhood characteristics included objective measures based on census tracts (family income, poverty, deprivation, residential stability, and percent white, black, or foreign-born) and self-reported neighborhood social ties. Using Cox proportional hazard models, we compared neighborhood mortality effects for people with versus people without a history of stroke. Most neighborhood variables predicted mortality for both stroke patients and the general population in demographic-adjusted models. Neighborhood percent white predicted lower mortality for stroke survivors (hazard ratio, 0.75 for neighborhoods in highest 25th percentile versus below, 95% confidence interval, 0.62-0.91) more strongly than for stroke-free adults (hazard ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.04 for stroke-by-neighborhood interaction). No other neighborhood characteristic had different effects for people with versus without stroke. Neighborhood-mortality associations emerged within 3 months after stroke, when associations were often stronger than among stroke-free individuals. CONCLUSIONS: Neighborhood characteristics predict mortality, but most effects are similar for individuals without stroke. Eliminating disparities in stroke survival may require addressing pathways that are not specific to traditional poststroke care.

Does neighborhood collective efficacy for families change over time? The Boston Neighborhood Survey.

There is an increased interest in how neighborhood social processes, such as collective efficacy, may protect mental health. Yet little is known about how stable these neighborhood processes are over time, or how to change them to influence other downstream factors. We used a population-based, repeat cross-sectional study of adults (n=5135) to assess stability of collective efficacy for families in 38 Boston neighborhoods across 4 years (2006, 2008, 2010) (the Boston Neighborhood Survey). We test temporal stability of collective efficacy for families across and within neighborhoods using 2-level random effects linear regression, fixed effects linear regression, T-tests, and Wilcoxon rank tests. Across the different methods, neighborhood collective efficacy for families remained stable across 4 years, after adjustment for neighborhood composition. If neighborhood collective efficacy is measured within 4 years of the exposure period of interest, assuming temporal stability may be valid.

Long-term rate of change in memory functioning before and after stroke onset.

BACKGROUND AND PURPOSE: Memory impairment is a predictor and a consequence of stroke, but memory decline is common even in healthy elderly individuals. We compared the long-term trajectory of memory functioning before and after stroke with memory change in stroke-free elderly individuals. METHODS: Health and Retirement Study participants aged 50 years and older (n=17 340) with no stroke history at baseline were interviewed biennially up to 10 years for first self-reported or proxy-reported stroke (n=1574). Age-, sex-, and race-adjusted segmented linear regression models were used to compare annual rates of change in a composite memory score before and after stroke among 3 groups: 1189 stroke survivors; 385 stroke decedents; and 15 766 cohort members who remained stroke-free. RESULTS: Before stroke onset, individuals who later survived stroke had significantly (P<0.001) faster average annual rates of memory decline (-0.143 points per year) than those who remained stroke-free throughout follow-up (-0.101 points per year). Stroke decedents had even faster prestroke memory decline (-0.212 points per year). At stroke onset, memory declined an average of -0.369 points among stroke survivors, comparable with 3.7 years of age-related decline in stroke-free cohort members. After stroke, memory in stroke survivors continued to decline at -0.142 points per year, similar to their prestroke rates (P=0.93). Approximately 50% of the memory difference between stroke survivors soon after stroke and age-matched stroke-free individuals was attributable to prestroke memory. CONCLUSIONS: Although stroke onset induced large decrements in memory, memory differences were apparent years before stroke. Memory declines before stroke, especially among those who did not survive the stroke, were faster than declines among stroke-free adults.