Understanding Associations Between Serious Mental Illness and Hepatitis C among Veterans: A National Multivariate Analysis Seth Himelhoch, MD, MPH,1,2.

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Understanding Associations Between Serious Mental Illness and Hepatitis C among Veterans: A National Multivariate Analysis Seth Himelhoch, MD, MPH,1,2 John F. McCarthy, PhD3,4 Dara Ganoczy, MPH, 3,4 Richard Goldberg, PhD, 1,2 Amy Kilbourne, Phd, 3,4 Deborah Medoff, PhD,1,2 Lisa Dixon, MD, MPH,1,2 and Frederic Blow, PhD 3,4 1 Veterans Affairs, MIRECC,VISN 5; 2 University of Maryland, School of Medicine, Department of Psychiatry; 3Veterans Affairs SMITREC VISN 11; 4University of Michigan, School of Medicine, Department of Psychiatry

REPORTED PREVALENCE OF HCV AMONG INDIVIDUALS WITH SMI Study Author Year HCV(%) Dewindle 2003 8.5 Pirl 2005 18.0 Rosenberg 2001 19.5 Meyer 20.3 Klinkenberg 30.0

REPORTED PREVALENCE OF HCV AMONG INDIVIDUALS WITH SMI Study Author Year HCV(%) Dewindle 2003 8.5 Pirl 2005 18.0 Rosenberg 2001 19.5 Meyer 20.3 Klinkenberg 30.0 General Population 1999 1.8

REPORTED PREVALENCE OF HCV AMONG INDIVIDUALS WITH SMI Study Author Year HCV(%) Dewindle 2003 8.5 Pirl 2005 18.0 Rosenberg 2001 19.5 Meyer 20.3 Klinkenberg 30.0 General Population 1999 1.8 V.A. Population 5.4

HCV PREVALENCE STUDIES AMONG INDIVIDUALS WITH SMI Variance in Estimates: Small Sample Sizes Differences in Sampling Frame Use of Convenience Samples No Comparison Groups: Unable to account for mediating or moderating factors

RESEARCH GOAL To determine the prevalence of Hepatitis C among a national population of veterans with SMI as compared to a non-SMI control group.

METHODS • Design: Cross-sectional study • Study Population: National population of veterans with a diagnosis of SMI from the National Psychosis Registry in Fiscal Year 2002

METHODS • Comparison Group: Random sample of veterans without a diagnosis of SMI in Fiscal Year 2002

METHODS • Comparison Group: Random sample of veterans without a diagnosis of SMI in Fiscal Year 2002 • Inclusion Criteria: Those who received at least 3 health care encounters at Veteran Affairs facilities during the fiscal year 2002.

METHODS • Predictor Variable: Diagnosis of SMI using the following ICD-9 codes for schizophrenia (295.0-4, 295.6-9),and bipolar disorder (296.0-1; 296.4-8)

METHODS • Predictor Variable: Diagnosis of SMI using the following ICD-9 codes for schizophrenia (295.0-4, 295.6-9),and bipolar disorder (296.0-1; 296.4-8) • Outcome Variable: Diagnosis of Hepatitis C using ICD-9 codes 070.41, 070.44, 070.51, and 070.54.

METHODS • Covariates: Substance Use Marital Status ICD-9 Codes for alcohol, cocaine, opioid type, cannibis, and combinations of drugs Marital Status

METHODS • Covariates: Substance Use Marital Status ICD-9 Codes for alcohol, cocaine, opioid type, cannibis, and combinations of drugs Marital Status Demograhic Characteristics, Region, Locale, Homelessness, Service Connection

ANALYSIS • Bivariate and multivariate logistic regression, outcome diagnosis of Hepatitis C

RESULTS

SAMPLE CHARACTERISTICS Schizophrenia N=89,189 Bipolar D/O N=65,983 Non-SMI N=67,965 Age (SD) * 55.1(11.9) 53.3 (12.4) 63.9 (13.9) Male (%) * 94.8 88.7 72.6 Black (%) * 27.6 11.4 10.2 Homeless (%) * 12.9 15.0 2.0 Urban (%) * 81.6 79.1 Sub. Use (%) * 24.8 32.7 6.2 Married (%) * 25.2 37.3 61.7 *P<0.0001

PREVALENCE OF HEP C 8.2% 7.1% 2.5%

PREVALENCE OF HEP C P<0.001 8.2% 7.1% 2.5%

PREVALENCE OF HEP C P<0.001 8.2% 7.1% 2.5%

CRUDE ODDS OF HEP C 2.94 (2.79,3.11) 3.43 (3.24,3.62) 1.00 (referent) Diagnostic Category Crude Odds Ratio (95% Confidence Interval) Schizophrenia 2.94 (2.79,3.11) Bipolar Affective Disorder 3.43 (3.24,3.62) Non-SMI Comparison 1.00 (referent)

CRUDE ODDS OF HEP C 2.94 (2.79,3.11) 3.43 (3.24,3.62) 1.00 (referent) Diagnostic Category Crude Odds Ratio (95% Confidence Interval) Schizophrenia 2.94 (2.79,3.11) Bipolar Affective Disorder 3.43 (3.24,3.62) Non-SMI Comparison 1.00 (referent) Those with SMI have ~3-3 1/2 times the risk for Hep. C as compared to Non-SMI Control Group.

FINAL LOGISTIC REGRESSION MODEL Adjusted for demographic characteristics, marital status, homelessness, substance use, region, locale, service connection.

FINAL LOGISTIC REGRESSION MODEL Adjusted for demographic characteristics, marital status, homelessness, substance use, region, locale, service connection. Significant interaction between diagnostic category and substance use

ADJUSTED ODDS OF HEP C Diagnostic Category Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Schizophrenia 2.94 (2.79,3.11) Without Substance Use 1.47 (1.36, 1.59) With Substance Use 5.95 (5.51, 6.43) Bipolar Affective D/O 3.43 (3.24,3.62) 1.64 (1.51, 1.78) 7.02 (6.50, 7.57) Non-SMI Comparison 1.00 (referent)

ADJUSTED ODDS OF HEP C Diagnostic Category Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Schizophrenia 2.94 (2.79,3.11) Without Substance Use 1.47 (1.36, 1.59) With Substance Use 5.95 (5.51, 6.43) Bipolar Affective D/O 3.43 (3.24,3.62) 1.64 (1.51, 1.78) 7.02 (6.50, 7.57) Non-SMI Comparison 1.00 (referent)

ADJUSTED ODDS OF HEP C Diagnostic Category Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Schizophrenia 2.94 (2.79,3.11) Without Substance Use 1.47 (1.36, 1.59) With Substance Use 5.95 (5.51, 6.43) Bipolar Affective D/O 3.43 (3.24,3.62) 1.64 (1.51, 1.78) 7.02 (6.50, 7.57) Non-SMI Comparison 1.00 (referent)

ADJUSTED ODDS OF HEP C Race Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Black 2.00 (1.93,2.08) 1.40 (1.34, 1.47) Hispanic 1.58 (1.48,1.68) 1.65 (1.53, 1.78) Other/Unknown 0.40 (0.38,0.43) 0.68 (0.63, 0.73) White 1.00 (referent)

ADJUSTED ODDS OF HEP C Marriage Category Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Never Married 2.41 (2.30,2.52) 1.24 (1.18, 1.31) Divorced/Separated 3.13 (3.00,3.26) 1.51 (1.43, 1.58) Widowed 1.02 (0.93,1.13) 1.02 (0.91,1.14) Married 1.00 (referent)

ADJUSTED ODDS OF HEP C Substance Use Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Yes 7.32 (7.07, 7.57) 5.48 (4.91, 6.12) No 1.00 (referent)

CONCLUSIONS Those with SMI have:

CONCLUSIONS Those with SMI have: ~3-3.5 times the crude prevalence of Hepatitis C

CONCLUSIONS Those with SMI have: Co-occuring Substance Use: ~3-3.5 times the crude prevalence of Hepatitis C Co-occuring Substance Use:

CONCLUSIONS Those with SMI have: Co-occuring Substance Use: ~3-3.5 times the crude prevalence of Hepatitis C Co-occuring Substance Use: Modifies Relationship Between HCV and Schizophrenia/Bipolar Disorder

CONCLUSIONS Those with SMI have: Co-occuring Substance Use: ~3-3.5 times the crude prevalence of Hepatitis C Co-occuring Substance Use: Modifies Relationship Between HCV and Schizophrenia/Bipolar Disorder Those with Bipolar Disorder:

CONCLUSIONS Those with SMI have: Co-occuring Substance Use: ~3-3.5 times the crude prevalence of Hepatitis C Co-occuring Substance Use: Modifies Relationship Between HCV and Schizophrenia/Bipolar Disorder Those with Bipolar Disorder: At Greater Risk Compared to those with Schizophrenia

LIMATIONS • Cross-Sectional Design

LIMATIONS • Cross-Sectional Design • Not Identify All Hep C patients

LIMATIONS • Cross-Sectional Design • Not Identify All Hep C patients • Generalizablity

IMPLICATIONS • Hepatitis C Screening Recommend

IMPLICATIONS • Hepatitis C Screening Recommend • Evaluate Substance Use

IMPLICATIONS • Hepatitis C Screening Recommend • Evaluate Substance Use • STIRR Intervention

ADJUSTED ODDS OF HIV Age Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) 50> years 0.42 (0.36, 0.48) 0.55 (0.48, 0.64) 40-49 years 1.46 (1.26, 1.68) 1.16 (1.00, 1.35) <40 years 1.00 (referent)

ADJUSTED ODDS OF HIV Male Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Yes 2.12 (1.69, 2.67) 2.74 (2.17, 3.46) No 1.00 (referent)

ADJUSTED ODDS OF HIV Urban Locale Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Yes 3.49 (2.98, 4.09) 2.12 (1.80, 2.49) No 1.00 (referent)

ADJUSTED ODDS OF HIV Service Connected Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Yes 0.85 (0.78, 0.92) 0.91 (0.83, 0.99) No 1.00 (referent)

ADJUSTED ODDS OF HIV Homeless Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Yes 3.28 (2.98, 3.61) 1.07 (0.96, 1.19) No 1.00 (referent)

ADJUSTED ODDS OF HIV Region Crude Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI) Central 0.65 (0.56,0.76) 0.66 (0.57,0.77) Northeast 1.54 (1.36,1.74) 1.40 (1.24,1.59) South 1.14 (1.01,1.28) 1.16 (1.02,1.31) West 1.00 (referent)