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JOURNAL OF DUAL DIAGNOSIS, 7(1–2), 4–13, 2011 ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2011.568306
PSYCHOTHERAPY & PSYCHOSOCIAL ISSUES
Dual Diagnosis in an Aging Population: Prevalence of Psychiatric Disorders, Comorbid Substance Abuse,
and Mental Health Service Utilization in the Department of Veterans Affairs
Karin E. Kerfoot, MD, Ismene L. Petrakis, MD, and Robert A. Rosenheck, MD
Objective: In the context of an aging baby boom cohort with higher rates of substance use disorders than previous cohorts, the abuse of substances and dual diagnosis represent growing areas of concern among older adults. The aims of this study were to determine the current treated prevalence of major psychiatric illnesses, substance use disorders, and dual diagnosis across multiple age groups in a national sample of mental health patients and to examine associated service utilization. Methods: Using administrative data from specialty mental health clinics in the Department of Veterans Affairs (N = 911,725), treated prevalence of major psychiatric illnesses, substance use disorders, and dual diagnosis across multiple age groups were determined over a 1-year interval (FY 2009). Associated mental health service utilization was examined. Results: Treated prevalence of almost all major psychiatric and substance use disorders decreased with age, while dementias increased with age. Across all major psychiatric illnesses, documented comorbid substance abuse decreased with age. Those with dual diagnoses had higher utilization of outpatient services compared to those without substance use disorders. With older age, patients had fewer outpatient visits and reduced likelihood of psychiatric hospitalization, but incurred more inpatient days per episode. Conclusions: Treated prevalence of substance use disorders and dual diagnosis decreases with age, falling to approximately 10% in those older than 65. Questions remain regarding the possibility of underdiagnosis of substance use disorders in the elderly. (Journal of Dual Diagnosis, 7:4–13, 2011)
Keywords dual diagnosis, co-occurring, concurrent, substance abuse, older adult, geriatrics, veterans, health service use
This article is not subject to U.S. Copyright law. All authors are affiliated with the Department of Psychiatry, Yale University, New Haven, Connecticut, USA.
Address correspondence to Karin E. Kerfoot, MD, West Haven Veterans Affairs Medical Center #116-A, 950 Campbell Ave., West Haven, CT 06516, USA. E-mail: [email protected]
Dual Diagnosis in an Aging Population 5
Older adults comprise a dramatically growing and changing group within the American popula- tion. By 2030, the number of Americans aged 65 and older is expected to be twice as large as in 2000, growing from 35 million to 72 million, and representing nearly 20% of the total U.S. population (Federal Interagency Forum on Aging-Related Statistics, 2010). This segment will be increasingly composed of baby boomers, born between 1946 and 1964 (and first reaching age 65 in 2011). Given that this cohort has reported higher lifetime rates of drug and alcohol use and is significantly larger than previous cohorts, it has been anticipated that both substance use and comorbid substance use with psychiatric disorders will be growing areas of concern among older adults as they “age in” to geriatric status (Colliver, Compton, Gfroerer, & Condon, 2006; Gfroerer, Penne, Pemberton, & Folsom, 2003). Patients with both psychiatric and substance use disorders present unique challenges to psychiatric practice because this combination of disorders tends to adversely impact the course and severity of illness and retention in treatment (Gonzalez & Rosenheck, 2002).
Data collected in the 1980 Epidemiological Catchment Area study showed that substance use and mental health disorders, on their own, are significantly prevalent in the elderly. The 1-month prevalence for any psychiatric disorder among individuals aged 65 years and older was 12.3% (Regier et al., 1988). Most common in this age group were anxiety disorders (5.5%) and severe cognitive impairment (4.9%), while 0.9% met criteria for alcohol abuse/dependence at the time of the survey, some 30 years ago. Results from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093) of the general U.S. population revealed that 2.4% of older (65 years or older) men and 0.4% of older women (65 years or older) met diagnostic criteria for 12-month prevalence of alcohol abuse (Grant et al., 2004). In the mid-1990s, a survey of primary care patients reported a point prevalence of 31.7% of patients aged 60 years and older (N = 224) with at least one active psychiatric condition, while 4.5% of men and 0.8% of women had active alcohol abuse or dependence (Lyness, Caine, King, Cox, & Yoediono, 1999).
Prevalence of substance use disorders and concurrent psychiatric illness is not surprisingly much higher in mental health care settings. A University of Virginia geriatric psychiatry outpatient clinic sample (60 years and older; N = 140) found 20% to have a current substance use disorder: 11.4% with benzodiazepine dependence and 8.6% with alcohol dependence (Holroyd & Duryee, 1997). Of these, 93% had comorbid psychiatric illness. A second study of three private psychiatric inpatient settings showed that 37.6% of older inpatients (65 years or older) had dual diagnoses: 71% with alcohol abuse and 29% with both alcohol and other substance abuse (Blixen, McDougall, & Suen, 1997). A recent review examining dual diagnosis in the elderly highlighted not only the high prevalence of comorbid substance abuse and mental disorders in older adults, depending on the population, but also the association with increased suicidality and greater service utilization, in both inpatient and outpatient samples (Bartels, Blow, van Citters, & Brockmann, 2006).
A previous Veterans Affairs (VA) study (N = 91,752) examined the prevalence of dual diagnosis and service use among mental health program patients in fiscal year 1990 and found that the percentage of veterans with dual diagnoses declined significantly and steadily with age, dropping from 30.4% of those younger than 55 to 4.4% of veterans aged 75 and older (Prigerson, Desai, & Rosenheck, 2001). Patients were then split into two age groups, with those aged 55 years and older referred to as “elderly” and those younger than 55 years designated as “non- elderly.” The elderly with dual diagnoses had longer inpatient stays for substance abuse and more outpatient substance abuse visits than did the elderly without dual diagnoses. Furthermore, elders with dual diagnoses had more outpatient general psychiatric visits than other contrast groups, but
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6 K. E. Kerfoot et al.
comparisons across specific psychiatric diagnoses were not reported. While it was concluded that dual diagnosis appeared less common among older patients, their heavy use of certain services (particularly outpatient) could represent an increasing burden if more patients with dual diagnoses survived to old age. It was noted that one explanation for the relatively low prevalence of dual diagnosis in later life may be selective mortality.
Understanding the prevalence of substance use disorders among patients with psychiatric comorbidity is important in order to assess psychiatric needs and plan for expanding integrated psychiatric and substance abuse treatment services (Drake et al., 2001) among the growing number of elders. In the context of an aging baby boom cohort, understanding the needs of an older population of substance abusers is particularly relevant. The aims of this study were to determine the treated prevalence of major psychiatric illnesses, substance use disorders, and dual diagnosis specific to each psychiatric illness across multiple age groups in a national sample of VA mental health service users and to examine mental health service utilization within these groups.
METHODS
Sample and Sources of Data
Data were derived from a registry of all patients treated in specialty mental health programs nationally in the U.S. Department of VA during a 1-year interval (October 1, 2008–September 30, 2009). The registry was compiled from the Outpatient Care File and the Outpatient Encounter File (national databases of information concerning all outpatient services delivered in the VA) and the Patient Treatment File, which compiles discharge abstracts on all episodes of VA inpatient care. All veterans who had at least one specialty mental health visit or at least one bed day of inpatient care in a psychiatric hospital program were included in the analysis (N = 911,725). The study was approved for a waiver of informed consent by the institutional review board at the VA Connecticut Healthcare System and Yale University in full conformance with the Declaration of Helsinki.
Measures
Data were available on age and diagnoses in the following subcategories: Dementia/Alzheimer’s Disease (290.00–290.99, 294.10, 331.00), Alcohol Abuse/Dependence (303.xx, 305.00), Drug Abuse/Dependence (292.01–292.99, 304.xx, 305.20–305.99), Schizophrenia (295.xx), Bipolar Disorder (296.0x, 296.1x, 296.40–296.89), Major Affective Disorder (296.2–296.39), Other De- pression (300.4x, 296.9x, 311.xx, 301.10–301.19), Posttraumatic Stress Disorder (309.81), Anx- iety Disorders (300.xx excluding 300.4), Adjustment Disorder (309.xx excluding 309.81), and Personality Disorders (301.0x, 301.2x–301.99). Outpatient psychiatric and substance abuse spe- cialty care visits and inpatient bed days of care in mental health programs were identified by standardized VA clinic codes and inpatient bed section codes (specific codes available on request). A dichotomous variable was created to identify those who had a diagnosis of a substance use disorder, defined as individuals who had at least one outpatient encounter or bed day with an
Journal of Dual Diagnosis
Dual Diagnosis in an Aging Population 7
alcohol- or drug-related diagnosis. Data on patient characteristics such as sex, race, marital status, and income were also derived from the VA workload databases.
Analyses
To examine the characteristics, diagnoses, and mental health service utilization of this population, older age groups were created as follows: 55 to 64 years, 65 to 74 years, 75 to 84 years, and 85 to 94 years. For purposes of comparison, a grouping of younger adult veterans, aged 35 to 54 years, was also created. For each age group, demographic characteristics were examined, including sex, race, marital status, and mean income. Treated prevalence of major psychiatric disorders and substance use disorders were determined across age groups. Treated prevalence of clinically diagnosed comorbid substance use disorders, within major psychiatric illnesses and across age groups, were then determined. Mental health service utilization, across age groups and in veterans with and without comorbid substance use diagnoses, was examined. Categorical service use variables consisted of (a) use of any general psychiatric outpatient services, (b) use of any substance abuse outpatient services, and (c) use of any mental health inpatient care. Continuous service use variables consisted of (a) number of outpatient visits (in total and separately for general psychiatric and substance abuse treatment) and (b) number of psychiatric inpatient bed days of care, for those patients with any such days. Because this study dealt with an entire population (veterans who use VA services), inferential statistics did not have relevance to the analysis.
RESULTS
A total of 911,725 VA patients aged 35 to 94 years were identified as having received VA mental health care in FY 2009. As shown in Table 1, the largest group was between the ages of 55 and 64 years (44.5%). Nearly 35.6% of the population was 35 to 54 years old, while 10.4% were 65 to 74 years, 7.3% were 75 to 84 years, and 2.3% were 85 to 94 years. The population was predominantly male (92.1%), which is consistent with the composition of the veteran population. Much of the data on race were unknown (60.9%), although 26.6% were identified as White, 9% as Black, and 3.2% as Hispanic. Marital status varied significantly with age, with older patients more likely to be married or widowed. Average income was lowest among the youngest age group, although large standard deviations were present in all groups.
As seen in Table 2, the percentage of veterans with diagnosed alcohol and other substance use disorders decreased significantly and monotonically with age, as did diagnoses of schizophrenia, major depressive disorder, and personality disorders. The highest treated prevalence of post- traumatic stress disorder (52.9%) was seen in the 55 to 64 years age group (consistent with the age range of Vietnam-era veterans). As expected, organic brain syndrome (encompassing Alzheimer’s disease and other etiology-specific dementias) was diagnosed more frequently with increasing age, reaching a maximum treated prevalence of 23.5% among those 85 to 94 years old. “Other psychiatric illnesses” (which encompassed most additional psychiatric diagnoses not already presented in Table 2) also showed increasing prevalence with advancing age. The three most prevalent diagnoses in this category were mood disorder due to a general medical condition, dementia not otherwise specified, and cognitive disorder not otherwise specified.
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8 K. E. Kerfoot et al.
TABLE 1 Sample Characteristics
35–54 Years 55–65 Years 65–74 Years 75–84 Years 85–94 Years 35–94 Years (n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n = 20,608) (N = 911,725)
% of sample 35.6 44.5 10.4 7.3 2.3 100.0 Sex (%)
Male 84.4 95.8 97.0 98.3 95.9 92.1 Female 15.6 4.2 3.0 1.7 4.1 7.9
Ethnicity (%) White/Caucasian 19.4 27.9 34.6 38.5 38.6 26.6 Black/African American 10.6 9.0 6.9 5.2 3.7 9.0 Hispanic 2.4 3.3 3.8 5.0 3.7 3.2 Other 0.3 0.5 0.4 0.4 0.6 0.3 Unknown 67.3 59.3 54.3 50.9 53.4 60.9
Marital Status (%) Married 36.5 50.9 56.3 63.9 60.0 47.5 Divorced 32.4 30.5 25.9 13.9 7.7 29.0 Never married 27.8 14.7 10.8 7.1 4.5 18.1 Widowed 1.5 3.1 6.3 14.5 26.7 4.2 Unknown 1.8 0.8 0.7 0.6 1.1 1.2
Mean income (SD) 18,163 (26,556)
26,782 (44,833)
29,555 (59,757)
29,979 (65,089)
28,553 (61,329)
23,014 (42,057)
Note. Mean income is given in U.S. dollars.
Percentages of patients with specific major psychiatric illnesses who also received a diagnosis of a co-morbid substance use disorder are presented in Table 3. In all diagnostic categories, comorbid substance use disorders were diagnosed less frequently in older adults. Co-occurring substance use disorders were diagnosed most commonly among veterans with personality disor- ders (47.8%) and least frequently among those with organic brain syndrome (6.6%).
Table 4 details mental health service utilization among veterans in each age group. Approxi- mately 97% of the sample used any general psychiatric outpatient services, with percentages only slightly increasing with age. Older patients utilizing general psychiatric outpatient services were significantly less likely to be documented as having received treatment for a comorbid substance use disorder, reaching a low of 2.2% among the oldest age group.
Use of any outpatient substance abuse treatment declined significantly with age, dropping from 20.3% among 35- to 54-year-olds to 1.1% among 85- to 94-year-olds. Interestingly, among patients who attended outpatient substance abuse visits, the older groups were less likely to have received treatment for a documented substance use disorder. For example, 93.3% of 35- to 54-year-olds attending outpatient substance use visits had a documented substance use disorder, while only 59% of 85- to 94-year-olds attending outpatient substance use visits were actually documented as having a substance use disorder. The likelihood of psychiatric hospitalization declined significantly with age, as did the documented treatment of a comorbid substance use disorder among hospitalized patients.
On average, veterans with diagnosed substance use disorders had significantly more outpatient general psychiatric and substance abuse visits than those without such disorders, across all age categories (see Table 4). Mean outpatient service utilization, measured as numbers of services
Journal of Dual Diagnosis
Dual Diagnosis in an Aging Population 9
TABLE 2 Age Distributions of Clinical Diagnostic Frequencies Among VA Mental Health Service Users
35–54 Years 55–65 Years 65–74 Years 75–84 Years 85–94 Years (n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n = 20,608)
Alcohol use disorder n = 180,756 (19.8%) 86,961 (26.8%) 78,836 (19.4%) 11,385 (12%) 3,173 (4.8%) 401 (2%) Other substance use disorder n = 148,001 (16.2%) 85,737 (26.4%) 56,226 (13.9%) 4,816 (5.1%) 1,044 (1.6%) 178 (0.9%) Any substance use disorder n = 245,154 (26.9%) 122,078 (37.6%) 104,755 (25.8%) 13,837 (14.6%) 3,923 (5.9%) 561 (2.7%) Organic brain syndrome n = 22,076 (2.4%) 519 (0.2%) 2,691 (0.7%) 3,709 (3.9%) 10,309 (15.5%) 4,848 (23.5%) Schizophrenia n = 79,018 (8.7%) 33,640 (10.4%) 33,313 (8.2%) 7,681 (8.1%) 3,671 (5.5%) 713 (3.5%) Bipolar disorder n = 84,198 (9.2%) 43,349 (13.4%) 29,522 (7.3%) 7,681 (8.1%) 3,119 (4.7%) 527 (2.6%) Major depressive disorder n = 206,776 (22.7%) 80,944 (25%) 90,552 (22.3%) 20,784 (21.9%) 11,742 (17.7%) 2,754 (13.4%) Other depression n = 425,508 (46.7%) 160,930 (49.6%) 183,455 (45.3%) 43,848 (46.2%) 29,189 (43.9%) 8,086 (39.2%) Posttraumatic stress disorder n = 359,137 (39.4%) 94,194 (29%) 214,615 (52.9%) 27,834 (29.3%) 16,892 (25.4%) 5,602 (27.2%) Anxiety disorder n = 221,549 (24.3%) 88,098 (27.2%) 89,031 (22%) 23,845 (25.1%) 16,026 (24.1%) 4,549 (22.1%) Adjustment disorder n = 93,203 (10.2%) 43,446 (13.4%) 33,095 (8.2%) 8,627 (9.1%) 6,164 (9.3%) 1,871 (9.1%) Personality disorder n = 35,469 (3.9%) 19,734 (6.1%) 12,818 (3.2%) 1,962 (2.1%) 787 (1.2%) 168 (0.8%) Other psychiatric diagnosis n = 204,645 (22.5%) 72,823 (22.5%) 77,731 (19.2%) 22,550 (23.8%) 22,930 (34.5%) 8,611 (41.8%)
received, decreased significantly in older age groups. In contrast, average inpatient days per year among those hospitalized tended to increase with age, among both veterans with diagnosed substance use disorders and those without. Substance users in all age groups had lower inpatient utilization than those without documented substance use disorders.
DISCUSSION
The results of this study suggest that among veterans accessing mental health care services in the VA healthcare system nationally, (a) the treated prevalence of almost all major psychiatric and substance use disorders decrease with age, while dementias increase with age; (b) across all major psychiatric illnesses, documented comorbid substance abuse decreases with age; (c) those with dual diagnoses have higher utilization of outpatient services, compared to those without substance use disorders; and (d) in older age groups, patients generally have fewer outpatient visits and reduced likelihood of psychiatric hospitalization, but incur more inpatient bed days of care per year.
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10 K. E. Kerfoot et al.
TABLE 3 Prevalence of Clinically Diagnosed Comorbid Substance Use Disorders by Psychiatric Diagnosis Within
Age Groups
35–54 Years 55–65 Years 65–74 Years 75–84 Years 85–94 Years (n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n = 20,608)
Organic brain syndrome n = 22,076 (2.4%) 163 (31.4%) 499 (18.5%) 308 (8.3%) 384 (3.7%) 98 (2%) Schizophrenia n = 79,018 (8.7%) 12,136 (36.1%) 8,258 (24.8%) 816 (10.6%) 162 (4.4%) 15 (2.1%) Bipolar disorder n = 84,198 (9.2%) 19,002 (43.8%) 9,155 (31%) 1,235 (16.1%) 214 (6.9%) 21 (4%) Major depressive disorder n = 206,776 (22.7%) 27,599 (34.1%) 23,348 (25.8%) 2,916 (14%) 757 (6.5%) 70 (2.5%) Other depression n = 425,508 (46.7%) 61,229 (38.1%) 29,936 (27.2%) 6,327 (14.4%) 1,713 (5.9%) 206 (2.6%) Posttraumatic stress disorder n = 359,137 (39.4%) 29,449 (31.3%) 47,925 (22.3%) 3,393 (12.2%) 772 (4.6%) 91 (1.6%) Anxiety disorder n = 221,549 (24.3%) 30,985 (35.2%) 22,450 (25.2%) 3,074 (12.9%) 853 (5.3%) 110 (2.4%) Adjustment disorder n = 93,203 (10.2%) 15,464 (35.6%) 9,105 (27.5%) 1,124 (13%) 336 (5.5%) 45 (2.4%) Personality disorder n = 35,469 (3.9%) 10,912 (55.3%) 5,442 (42.5%) 493 (25.1%) 100 (12.7%) 10 (6%) Other psychiatric diagnosis n = 204,645 (22.5%) 32,571 (44.7%) 25,058 (32.2%) 3,935 (17.5%) 1,456 (6.4%) 247 (2.9%)
Treated prevalence of substance use disorders and dual diagnosis continue to decline with age among veterans. These patterns are consistent with previous findings in the general population (Grant et al., 2004) and clinical populations (Prigerson et al., 2001). Despite this, the numbers are still considerable, particularly in the context of an increasingly large geriatric population. In comparison to the relatively extensive literature on co-occurring disorders in younger adults, little attention has been given to the published characterization, outcomes, and treatment of concurrent disorders in older age (Bartels et al., 2006). Although projections have been offered, the actual impact of aging baby boomers on this area remains largely unknown.
Interestingly, among older veterans who utilized outpatient substance abuse services, increas- ingly fewer patients actually received substance use disorder diagnoses. It is possible that these patients had a more distant history of substance use disorders (now in longstanding remission) but continued to access services in order to prevent relapse without receiving a recorded diagnosis. It is also possible that despite being seen in substance abuse clinics, a substance-related diagnosis was not recorded because clinicians were reluctant to add a new substance-related diagnosis to an older veteran’s chart, diagnostic criteria were not met, or the relevant diagnosis was simply not recorded.
One explanation for some component of the declining patterns seen in this study may be early mortality. The concurrence of psychiatric illness with substance abuse is associated with vulnerability to premature death. Disordered substance use comorbid with mental illness is likely to shorten life expectancy, thereby selectively removing individuals with dual diagnoses from older age groups.
Journal of Dual Diagnosis
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There is also likely to be underrecognition of substance use disorders among the elderly. Underdiagnosis is thought to occur more frequently in the elderly for several reasons (Culberson, 2006a). First, there may be societal reluctance to give older people a diagnosis that is perceived as pejorative. Second, visible consequences of substance abuse, such as falls or confusion, may be attributed to comorbid medical illnesses or aging itself. Third, there may be a false assumption that the onset of substance use disorders rarely occurs late in life, although it has been increasingly recognized that disruptive life events, such as retirement or death of a spouse, may trigger new-onset substance misuse in later life (Rigler, 2000). Finally, the DSM diagnostic criteria for substance abuse or dependence may not appropriately identify older patients with dysfunctional patterns of use, particularly in the context of comorbid medical illnesses, physiological and cognitive changes associated with age, and polypharmacy.
Increased detection of substance use problems in older adults may be achieved through the development of screening tools specifically intended for elderly populations (Culberson, 2006b). For example, the Short Michigan Alcohol Screening Test–Geriatric Version is a 10-item screening tool focused on negative consequences of alcohol use specific to older adults. The Alcohol- Related Problems Survey (APRS) is a 10-minute questionnaire (completed alone or with family assistance) that explores the relationship between alcohol consumption and worsening health, medication use, and declining functional status. Furthermore, recognition by clinical providers that even brief interventions can be effective in producing positive change may increase clinician interest in identifying older patients with substance use issues.
Limitations of this study include reliance on administrative data, which are not based on validated diagnostic assessments by trained personnel. Treatment prevalence is the sole source of data in this cross-sectional study. Older adults are generally underrepresented within psy- chiatric treatment populations (both inpatient and outpatient), limiting our ability to draw con- clusions about changes in the prevalence of dual diagnosis related to age. Furthermore, the study examined prevalence rates of diagnosed psychiatric and substance use disorders, but did not provide direct information on clinical severity, such as level of symptomatology or prognosis.
Data were not available on general disability status, including social security disability. The data in this study pertain to veterans served by the VA, who are overwhelmingly male and known to be older, poorer, and less likely to have health insurance than those who do not use VA services (Rosenheck, 2004). Older adults seeking treatment in specialty mental health clinics are also recognized to be nonrepresentative of the general geriatric population, the majority of whom receive treatment in primary health care settings. Thus, the generalizability of this study’s findings to non-VA populations, veterans or not, is unknown. Nevertheless, within that group, use of these administrative data provides information on a full national sample treated in specialty mental health programs across the country.
This study represents one of the few published thus far evaluating the treated prevalence of major psychiatric and substance use disorders among elderly Americans, and it compares the prevalence of dual diagnosis and service utilization within specific psychiatric diagnoses across age groups. The results of this study may be useful in program planning and understanding treatment needs. It generally suggests declining substance use and dual diagnosis among the elderly, but it may also raise concern about the possible underdiagnosis of substance use disorders among the elderly and the need for appropriate screening, diagnosis, and treatment.
Journal of Dual Diagnosis
Dual Diagnosis in an Aging Population 13
ACKNOWLEDGMENTS
Support was provided by the Department of Veterans Affairs VISN 1 Mental Illness Research, Education and Clinical Center.
DISCLOSURES
Dr. Kerfoot reports no financial relationships with commercial interests. Dr. Petrakis reports no financial relationships with commercial interests. Dr. Rosenheck has no disclosures to report regarding financial interests.
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2011, Volume 7, Numbers 1–2
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