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Trends in the Diagnosis of Diseases of Despair in the United States, 2009–2018: a Retrospective Cohort Study

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Trends in the Diagnosis of Diseases of Despair in the United States, 2009–2018: a Retrospective Cohort Study Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-037679 on 9 November 2020. Downloaded from Trends in the diagnosis of diseases of despair in the United States, 2009–2018: a retrospective cohort study Emily Brignone ,1 Daniel R George,2,3 Lawrence Sinoway,3,4 Curren Katz,1 Charity Sauder,3 Andrea Murray,3 Robert Gladden,1 Jennifer L Kraschnewski3,4,5 To cite: Brignone E, George DR, ABSTRACT Strengths and limitations of this study Sinoway L, et al. Trends in Background and objective Increasing mortality the diagnosis of diseases of and decreasing life expectancy in the USA are largely despair in the United States, ► Increasing mortality due to deaths of despair is well 2009–2018: a retrospective attributable to accidental overdose, alcohol- related disease documented in extant research. To our knowledge, cohort study. BMJ Open and suicide. These ‘deaths of despair’ often follow years this study is the first to provide large- scale insights 2020;10:e037679. doi:10.1136/ of morbidity, yet little is known about trends in the clinical into the clinical recognition of the morbidities that bmjopen-2020-037679 recognition of ‘diseases of despair’. The objective of this can ultimately culminate in those deaths. This clini- study is to characterise rates of clinically documented ► Prepublication history for cal perspective highlights potential opportunities to this paper is available online. diseases of despair over the last decade and identify intervene in the progression of morbidity towards To view these files, please visit sociodemographic risk factors. mortality. the journal online (http:// dx. doi. Design Retrospective study using a healthcare claims ► The study uses a large and inclusive sample. As a org/ 10. 1136/ bmjopen- 2020- database with 10 years of follow- up. result, we are able to identify differential patterns in 037679). Setting Participants resided nationwide but were the diagnosis of substance-rela ted, alcohol-rela ted and suicide-rela ted diagnoses across age and gen- Received 13 February 2020 concentrated in US states disproportionately affected by der lines, which can improve targeted prevention Revised 12 May 2020 deaths of despair, including Pennsylvania, West Virginia Accepted 19 July 2020 and Delaware. efforts. Participants Cohort included 12 144 252 participants, ► The long administrative surveillance period of 10 with no restriction by age or gender. years allows us to track changes in the identification Outcome measures Diseases of despair were defined of diseases of despair over time, and to compare long-term trends between documented morbidity as diagnoses related to alcohol misuse, substance misuse and mortality. http://bmjopen.bmj.com/ and suicide ideation/behaviours. A lookback period was While trends in deaths of despair appear to vary by used to identify incident diagnoses. Annual and all- ► © Author(s) (or their race/ethnicity, details on race/ethnicity were not time incidence/prevalence estimates were computed, employer(s)) 2020. Re- use available for our sample. permitted under CC BY- NC. No along with risk for current diagnosis and patterns of We were unable to directly link disease of despair commercial re- use. See rights ► comorbidity. incidence/prevalence to mortality on an individual and permissions. Published by Results 515 830 participants received a disease of BMJ. level; rather, we compare trends in morbidity and despair diagnosis (58.5% male, median 36 years). 1Data Science Research and mortality in more general terms. From 2009 to 2018, the prevalence of alcohol- related, Development, Highmark Health, Pittsburgh, Pennsylvania, USA substance- related and suicide- related diagnoses on September 30, 2021 by guest. Protected copyright. 2Department of Humanities, respectively increased by 37%, 94%, and 170%. Ages 55– Penn State College of Medicine, 74 had the largest increase in alcohol/substance- related From 2015 to 2017, there was an annual down- Hershey, Pennsylvania, United diagnoses (59% and 172%). Ages <18 had the largest ward trend in life expectancy in the USA, the States increase in suicide- related diagnoses (287%). Overall, 1 2 3 longest sustained decline since 1915–1918. Clinical and Translational odds for current-year diagnosis were higher among men Relatedly, researchers have observed a longer, Science Institute, Penn State (adjusted OR (AOR) 1.49, 95% CI 1.47 to 1.51), and among College of Medicine, Hershey, more marked increase in the all- cause Pennsylvania, United States those with Affordable Care Act or Medicare coverage mortality of middle-aged white non-Hispanic 4Department of Medicine, Penn relative to commercial coverage (AOR 1.30, 1.24 to 1.37; men and women in the USA between 1999 State College of Medicine, AOR 1.51, 1.46 to 1.55). and 2015, with premature deaths largely Hershey, PA, United States Conclusions Increasing clinical rates of disease of 5 associated with ‘deaths of despair’, including Department of Public despair diagnoses largely mirror broader societal trends Health Sciences, Penn State suicides, accidental poisonings (eg, opiate in mortality. While the opioid crisis remains a top public College of Medicine, Hershey, overdose) and alcohol-related liver disease Pennsylvania, United States health priority, parallel rises in alcohol-rela ted diagnoses (eg, cirrhosis).3 4 and suicidality must be concurrently addressed. Findings This troubling observation has coincided Correspondence to suggest opportunities for healthcare systems and with decades of economic decline for less Dr Emily Brignone; providers to deploy targeted prevention to mitigate the educated and unskilled workers, stagnant emily. brignone@ progression of morbidities towards mortality. highmarkhealth. org or falling real median wages and family Brignone E, et al. BMJ Open 2020;10:e037679. doi:10.1136/bmjopen-2020-037679 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-037679 on 9 November 2020. Downloaded from incomes,5 6 lower marriage rates,7 increases in single- within each of the three diagnostic categories of interest. parent households8 and disengagement from the labour Classifications were adapted from the Healthcare Cost force.9 It is theorised that these changes have fostered and Utilization Project Clinical Classification Software growing feelings of despair, that is, disillusionment, (HCUP- CCS).20 Code mappings were used for HCUP precariousness and resignation.3 4 10–12 Despair may in categories alcohol- related disorders (5.11), substance- turn trigger emotional, cognitive, behavioural and even related disorders (5.12), and suicide and intentional self- biological changes,13–17 increasing the likelihood of inflicted injury (5.13). Diagnoses related to substance use diseases that can progress and ultimately culminate in considered outside the focus of the present study were these deaths of despair. excluded, specifically, codes related to the use of tobacco While this pathway may unfold over years or decades, to and cannabis, and certain non-psychoactive substances date, most studies in this domain have primarily focused (ie, ICD-10 codes F550, F551, F552, F554). Additional on the endpoint of mortality. Limited extant research indicators were created for overall disease of despair suggests a parallel rise in associated morbidities,3 4 but status (diagnosis of any type), and co- occurring diseases specific estimates of ‘disease of despair’ morbidity (ie, of despair status (diagnoses in multiple categories). A substance- related disorders, alcohol-related disorders, 2- year lookback period was used to identify incident diag- and suicide ideation and attempts) are lacking. Moreover, noses. If no record of the given diagnosis type was found little is known about trends in the recognition and docu- during the lookback period, the diagnosis was recorded mentation of these diseases in the clinical setting. This as an incident case. Annual and all- time incidence and represents an important gap in the literature; indeed, prevalence estimates were computed. while primary prevention efforts to address the root causes Additional clinical comorbidities were calculated for of societal despair are needed, it may be possible to inter- the final year of follow- up (2018). Physical health comor- vene on the pathway from morbidity to mortality in the bidities were measured using weighted Charlson Comor- clinical setting. An understanding of diagnostic patterns bidity Index Scores.21 Psychiatric comorbidities were and the association between documented morbidity defined using additional HCUP-CCS classifications, and and mortality is necessary to guide these secondary and included indicators for adjustment/anxiety disorders tertiary prevention efforts. Thus, the objectives of the (5.1 and 5.2), mood disorders (5.8), and schizophrenia present study were to use a large administrative database and other psychotic disorders (5.10). of healthcare claims to (1) characterise the incidence Existing research points to particular age groups as and prevalence of diseases of despair diagnoses over the having uniquely high risk for deaths of despair overall last decade and (2) identify individual sociodemographic and by particular subtype. Thus, individuals in the sample factors and patterns of comorbidity associated with were stratified into age groups to allow for comparison disease of despair diagnosis. Finally, patterns in morbidity between morbidity and mortality trends. Infants less than and mortality are discussed. 1 year old were analysed separately
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