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April 19, 2007 — In 2004, 24% of adults admitted to community hospitals in the United States had mental-health and substance-abuse (MHSA) disorders, according to a recent report.

The report, Care of Adults with Mental Health and Substance Abuse Disorders in US Hospitals, 2004, was issued by the US Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ).

Coauthor Anne Elixhauser, PhD, from the AHRQ, in Rockville, Maryland, told Medscape that this was the first documentation of the impact of MHSA disorders on acute-care hospitals. "Part of the motivation for putting [the report] together was that we know that psychiatry hospitals have been closing and there are fewer psychiatric-treatment facilities," she explained. The finding that in 1 out of 4 hospital stays for adults there was some mention of mental-health illness was "really surprising," she said, adding, "We checked and double-checked the numbers."

The results are drawn from AHRQ's Healthcare Cost and Utilization Project (HCUP) data from community hospitals, which are defined as acute-care hospitals excluding federal hospitals (such as those for veterans), long-term-care institutions, or psychiatric hospitals. The team analyzed data from about 32 million hospital discharges from adult patients (age 18 years and older) and found that patients had a diagnosis of MHSA disorders in 7.6 million hospital stays. It was the primary diagnosis in 1.9 million hospital stays (6%) and a secondary diagnosis in 5.7 million hospital stays (18%).

"Shocking" Prevalence of Mood Disorders, Dementia

The most common MHSA disorders (in order of prevalence) were mood disorders (depressive and bipolar disorders), substance-related disorders (abuse, dependence, or withdrawal from drugs or alcohol), dementia/delirium, anxiety disorders, and schizophrenia. A diagnosis of mood disorder, substance-related disorders, or delirium/dementia was found in 1 in 10, 1 in 14, and 1 in 20 hospital stays, respectively.

Among adults younger than 80 years, mood disorders were the most common MHSA disorder, found in 11%, 13%, and 8% of hospitalized patients aged 18 to 44, 45 to 64, and 65 to 79 years, respectively. "It is shocking that among individuals aged 45 to 64 years old, 13% of all hospital stays included a diagnosis of mood disorders," Dr. Elixhauser said, adding that perhaps depression is a contributing condition to illnesses such as heart disease. She noted that substance-related disorders were found in about 10% of patients aged 18 to 64 years, but among hospitalized patients aged 65 to 79 years, substance abuse virtually disappeared and dementia was more common. She added that it is also "shocking" that 21% of patients aged 80 years and older had a diagnosis of dementia.

Gender Differences, Dual Diagnosis, Suicide

Other notable findings were that women were more likely than men to be hospitalized with MHSA disorders (58% vs 42%). Mood disorders were most common in women, whereas substance-related disorders were most common in men. In addition, 5% of women who were hospitalized for childbirth or pregnancy also had MHSA disorders.

About 3% of all hospital stays involved a dual diagnosis, defined as having both a mental-health disorder and a substance-related problem. This was most often seen in men (55% of cases) and in individuals aged 18 to 44 years (60% of cases).

Nearly 179,000 hospital stays were related to suicide or suicide attempts, mostly (72%) in individuals aged 18 to 44 years.

Cost Burden

Having a MHSA diagnosis (primary or secondary) was linked with a longer hospital stay than not having this diagnosis (5.8 vs 4.5 days).

Hospitalizations for the 5 most common MHSA diagnoses cost $9.9 billion in 2004. More than 66% of adult hospital stays with MHSA diagnoses were billed to the government (18% to Medicaid and 48% to Medicare). More than 78% of hospital stays for schizophrenia and 90% of hospital stays for dementia/delirium were billed to the government.

Significant Concerns, Need for Early Interventions

Elixhauser said this report highlights some areas of concern related to the care of adults with MHSA disorders in community hospitals, and they hope that it stimulates others to examine these issues more carefully.

In a press release issued by the AHRQ, Terry Cline, PhD, administrator for the Substance Abuse and Mental Health Services Administration (SAMHSA), said: "The significant number of hospital stays related to mental-health and substance-use disorder signals the need for an increased national effort to identify and intervene early before the conditions require a hospital stay."


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