Investigating the temporal relationship between individual-level social capital and health in fragile families.

BACKGROUND: The potential for social capital to influence health outcomes has received significant attention, yet few studies have assessed the temporal ordering between the two. Even less attention has been paid to more vulnerable populations, such as low-income women with children. Our objective was to explore how different dimensions of social capital impact future health status among this population. METHODS: This study uses data from the Fragile Families and Child Well-Being (FFCWB) Study, which has followed a cohort of children and their families born in large U.S. cities between 1998 and 2000 to mostly minority, unmarried parents who tend to be at greater risk for falling into poverty. Four separate measures of social capital were constructed, which include measures of social support and trust, social participation, perceptions of neighborhood social cohesion, and perceptions of neighborhood social control. The temporal effect of social capital on self-reported health (SRH) is investigated using logistic regression and we hypothesize that higher levels of social capital are associated with higher levels of self-rated health. RESULTS: After controlling for socioeconomic and demographic factors related to social capital and self-rated health, social support and trust, perceptions of neighborhood social cohesion and control at an earlier point in time were positively associated with higher levels of health four-years later. Social participation was not related to increased health. The empirical results appear robust. CONCLUSION: Higher levels of social capital are predictive of improved health over a four-year time frame. These results suggest that policy initiatives supporting increasing the social capital available and accessible by low-income, urban, minority women are viable for improving health. Such policies may have the potential to reduce socioeconomic health disparities.

Depression diagnoses following the identification of bipolar disorder: costly incongruent diagnoses.

BACKGROUND: Previous research has documented that the symptoms of bipolar disorder are often mistaken for unipolar depression prior to a patient's first bipolar diagnosis. The assumption has been that once a patient receives a bipolar diagnosis they will no longer be given a misdiagnosis of depression. The objectives of this study were 1) to assess the rate of subsequent unipolar depression diagnosis in individuals with a history of bipolar disorder and 2) to assess the increased cost associated with this potential misdiagnosis. METHODS: This study utilized a retrospective cohort design using administrative claims data from 2002 and 2003. Patient inclusion criteria for the study were 1) at least 2 bipolar diagnoses in 2002, 2) continuous enrollment during 2002 and 2003, 3) a pharmacy benefit, and 4) age 18 to 64. Patients with at least 2 unipolar depression diagnoses in 2003 were categorized as having an incongruent diagnosis of unipolar depression. We used propensity scoring to control for selection bias. Utilization was evaluated using negative binomial models. We evaluated cost differences between patient cohorts using generalized linear models. RESULTS: Of the 7981 patients who met all inclusion criteria for the analysis, 17.5% (1400) had an incongruent depression diagnosis (IDD). After controlling for background differences, individuals who received an IDD had higher rates of inpatient and outpatient psychiatric utilization and cost, on average, an additional $1641 per year compared to individuals without an IDD. CONCLUSIONS: A strikingly high proportion of bipolar patients are given the differential diagnosis of unipolar depression after being identified as having bipolar disorder. Individuals with an IDD had increased acute psychiatric care services, suggesting higher levels of relapses, and were at risk for inappropriate treatment, as antidepressant therapy without a concomitant mood-stabilizing medication is contraindicated in bipolar disorder. Further prospective research is needed to validate the findings from this retrospective administrative claims-based analysis.

Diagnosis of unipolar depression following initial identification of bipolar disorder: a common and costly misdiagnosis.

BACKGROUND: Bipolar disorder is challenging to diagnose in medical practice. OBJECTIVES: Our objectives were (1) to determine the rate of depression misdiagnosis in patients previously diagnosed with bipolar disorder in administrative claims, (2) to determine the resulting increased treatment costs, and (3) to verify the misdiagnoses in the medical charts for a subset of patients. METHOD: We employed cohort analysis using claims from a large, commercial, U.S. health plan from January 2001 through December 2003. Inclusion criteria included 2 bipolar disorder diagnoses (ICD-9-CM criteria), continuous enrollment for 1 year before and after initial bipolar disorder diagnosis, age 18-64 years, and a pharmacy benefit. Propensity scoring was used to control for differences between patients with and without 2 depression diagnoses in the year following their bipolar disorder diagnosis. Medical charts were obtained for 100 patients, including 76 with a bipolar disorder diagnosis chart from one provider and a depression diagnosis chart from a second provider. RESULTS: Of 3119 bipolar disorder patients meeting inclusion criteria, 857 (27.5%) had subsequent depression misdiagnoses during the follow-up year. These patients had 1.82 times more psychiatric hospitalizations and 2.47 times more psychiatric emergency room visits. For 673 patients (78.5%), a different provider gave the depression misdiagnosis. Annual per-patient treatment costs were significantly higher (p < .001) for those diagnosed with depression ($12,594) than for those not ($9405). In the chart review, both the bipolar disorder and subsequent depression diagnoses were confirmed for 65.8% (50/76) of the patients who had charts from 2 different providers. CONCLUSIONS: More than one quarter of individuals diagnosed with bipolar disorder received an ostensible depression misdiagnosis during the follow-up period. Significant (p = .001) increases in psychiatric inpatient hospitalization suggest that improvements in the continuity of care could improve outcomes and reduce costs.