Presented on June 11, 2013, CSTE Annual Conference 2013, Pasadena, CA. Public Health Surveillance Program Office

Transcription

1 Socioeconomic status and anxiety/stress/depression are associated with suicidal thoughts among adults who served in the U.S. military: A latent class analysis Xiao Jun (John) Wen, MD; Chaoyang Li, MD, PhD; Guixiang Zhao, MD, PhD; Alexander E. Crosby, MD, Matthew M. Zack, MD, MPH; Lina Balluz, Sc.D. MPH Centers for Disease Control and Prevention Presented on June 11, 2013, CSTE Annual Conference 2013, Pasadena, CA Office of Surveillance, Epidemiology, and Laboratory Services Public Health Surveillance Program Office

2 Background Suicide mortality among veterans and active military in the U.S has been a national concern in recent years Data source: VA Death per 100,000

3 Background Predictors for suicide death among veterans and active military in the U.S: - Being male, white, single, unemployed, and depressed - Risk factor assessments are usually done by multivariate logistic regression models

4 Background Limitations of single-indicator modeling: - It does not fully account for the correlation and overlap among individual suicide risk factors - Examples - Social economic status: employment and annual income level - Mental health status: depressive disorders, depression, anxiety, post-traumatic stress disorder - A risk factor may include multiple indicators, or it is a class of multiple factors in the same domain. Such risk factor can be very difficulty to handle by a single-indicator modeling approach

5 Background To identify class variables in the domains of socioeconomic status and mental health status as potential correlates of suicidal thoughts

6 Methods Data source Behavioral Risk Factor Surveillance System (BRFSS) 2011 data Optional model Sample used in the analysis -6,884 adult respondents who had served in the U.S. military (did not include those in training for the Reserves or National Guard and also excluded those who refused or answered do not know to the question about suicide thoughts) -Both landline and cell phone -Nine states participations (Alaska, Kansas, Louisiana, Maine, Nebraska, Nevada, New Jersey, North Carolina, and Tennessee)

7 Methods Outcome variable: suicidal thoughts Question asked about it: Has there been a time in the past 12 months when you thought of taking your own life?

8 Methods Questions asked about the economic status: Employment: Are you currently? (multiple choices on employment) Annual income: (How much) is your annual household income from all sources? Home ownership: Do you own or rent your home?

9 Methods Questions about mental health and treatment: (Ever told) you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)? (core questionnaire) Has a doctor or other health professional ever told you that you have depression, anxiety, or post traumatic stress disorder (PTSD)? In the past 12 months, did you receive any psychological or psychiatric counseling or treatment?

10 Methods Modeling of the Latent class variables Indicators Domains Outcome Covariates Age Employment Annual income Home ownership Social economic Sex Marital status Latent class variables Suicidal thoughts Health insurance coverage Smoking Depression/anxiety Depression/anxiety/ PTSD Received counseling treatment Mental health Physical activities Self-rated health Disability Traumatic brain injury

11 Probabilities Methods Probabilities of being at the low socioeconomic class by latent class analysis Non-low social class % of the sample Low social class % of the sample Unmployed or unable to work Household annual income <$25,000 Member of latent class in socioeconomic domain non-home owner

12 Probabilties Methods Probabilities of high risk of mental health by latent class analysis Mentally healthy class % of the sample Mentally unhealthy class -12.0% of sample 0 Depression Anxiety/depression/PTSD Received counseling/treatment Member of latent class in mental health domain

13 Methods Table 1 Fit of latent class models using Bayesian information criterion (BIC) and quality of models for health-related domains, Behavioral Risk Factor Surveillance System (BRFSS), 2011 No. of classes in the model Socioeconomic class Health-related Domain Mental health BIC Entropy BIC Entropy n/a n/a

14 Results Table 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011 Variable Unweighted sample No. * (%) Overall 6884 (100.0) years old 258 (12.6) years old 1183 (27.5) 55+ years old 5443 (60.0) Men 6342 (92.6) women 542 (7.4) Non-Hispanic white 5950 (79.3) Non-white 934 (20.7) Married 4486 (68.1) Previously married 1981 (22.2) Never married 417 ( 9.7) Employed 2458 (44.6) Unemployed 268 (6.3) Homemaker/student 93 (2.9) Retired 3617 (39.2) Unable to work 432 ( 7.2) education attainment 12 yrs or less 2445 (41.9) Some college or higher 4423 (58.1) Not covered by health plan 418 ( 8.8) Covered by health plan 6458 (91.2) Self-rated fair/poor Health 1572 (21.4) Self-rated good/excellent Health 5279 (78.6) With disability 2563 (33.3) No disability 4289 (66.7) Smoker 1090 (20.0) Former smoker/never smoked 5766 (80.0)

15 Results Table 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011 Non-binge drinker 6019 (87.4) Binge drinker 732 (12.6) non-heavy drinker 6397 (94.7) Heavy drinker 345 (5.3) Physically active in leisure time 4933 (71.6) Not physically active in leisure time 1938 (28.4) Served in combat/war zone 2751 (41.8) Not served in combat/war zone 4133 (58.2) Had traumatic brain injury 225 (3.7) No traumatic brain injury 6640 (96.3) Socioeconomic class latent variable Non-low socioeconomic class 6126 (86.4) Low socioeconomic class 758 (13.6) Unemployed or unable to work 700 (13.4) Employed/retired/students/home maker 6168 (86.6) Household annual income <$25, (24.4) Household annual income $25,000 +/unknown 4561 (75.6) Not own a home 990 (18.7) Own a home 5894 (81.3) Mental health latent variable Mentally healthy class 6150 (88.0) Mentally unhealthy class 734 (12.0) Had anxiety/depressive disorder 981 (15.0) No anxiety/depressive disorder 5872 (85.0) Had depression/anxiety/ptsd 895 (14.3) No depression/anxiety/ptsd 5955 (85.7) Received counseling in past 12 months 502 (9.2) Not received counseling in past 12 months 6368 (90.8)

16 Results Table 2 Sample descriptive statistics by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011 Variable Prevalence % (95% CI) p-value PR % (95% CI) Overall 4.8 ( ) n/a years old 9.2 ( ) ( ) years old 5.3 ( ) ( ) 55+ years old 3.6 ( ) Reference Reference Men 4.7 ( ) > ( ) women 5.8 ( ) Reference Reference Non-Hispanic white 4.6 ( ) Reference Reference Non-white 5.4 ( ) ( ) Married 3.6 ( ) Reference Previously married 6.8 ( ) ( ) Never married 8.4 ( ) ( ) Employed 2.9 ( ) Reference Reference Unemployed 16.0 ( ) ( ) Homemaker/student 5.2 ( ) ( ) Retired 3.2 ( ) ( ) Unable to work 14.8 ( ) < ( ) education attainment 12 yrs or less 5.2 ( ) ( ) Some college or higher 4.3 ( ) Reference Reference Not covered by health plan 14.5 ( ) ( ) Covered by health plan 3.8 ( ) Reference Reference Self-rated fair/poor Health 10.0 ( ) < ( ) Self-rated good/excellent Health 3.4 ( ) Reference Reference With disability 8.7 ( ) < ( ) No disability 2.6 ( ) Reference Reference Smoker 8.3 ( ) ( ) Former smoker/never smoked 3.9 ( ) Reference Reference

17 Results Table 2 Prevalence of self-reported suicidal thoughts by demographics, socioeconomic and mental health status, and risk factors among adults who served in the military, from nine states in U.S., 2011 Non-binge drinker 4.2 ( ) Reference Reference Binge drinker 7.9 ( ) ( ) non-heavy drinker 4.7 ( ) Reference Reference Heavy drinker 7.5 ( ) ( ) Physically active in leisure time 3.7 ( ) Reference Reference Not physically active in leisure time 7.4 ( ) ( ) Served in combat/war zone 4.8 ( ) ( ) Not served in combat/war zone 4.7 ( ) Reference Reference Had traumatic brain injury 12.9 ( ) ( ) No traumatic brain injury 4.4 ( ) Reference Reference Socioeconomic class latent variable Non-low socioeconomic class 3.3 ( ) Reference Reference Low socioeconomic class 13.9 ( ) < ( ) Unemployed or unable to work 15.4 ( ) Reference Reference Employed/retired/students/home maker 3.1 ( ) < ( ) Household annual income <$25, ( ) ( ) Household annual income $25,000 +/unknown 3.1 ( ) Reference Reference Not own a home 9.0 ( ) ( ) Own a home 3.8 ( ) Reference Reference Mental health latent variable Mentally healthy class 2.4 ( ) Reference Reference Mentally unhealthy class 22.1 ( ) < ( ) Had anxiety/depressive disorder 20.6 ( ) < ( ) No anxiety/depressive disorder 1.9 ( ) Reference Reference Had depression/anxiety/ptsd 18.9 ( ) < ( ) No depression/anxiety/ptsd 2.4 ( ) Reference Reference Received counseling in past 12 months 22.3 ( ) < ( ) Not received counseling in past 12 months 2.9 ( ) Reference Reference

18 Results Table 3 Adjusted Prevalence ratios of self-reported suicidal thoughts by latent classes of socioeconomic and mental health determinants among adults served in the military, from nine states in U.S., 2011 Variable Model 1 Model 2 Model 3 Socioeconomic class latent variable Non-low socioeconomic class Reference n/a Reference Low socioeconomic class 1.60 ( ) n/a 1.23 ( ) Mental health latent variable Mentally healthy class n/a Reference Reference Mentally unhealthy class n/a 5.89 ( ) 5.73 ( ) Aged yrs 2.22 ( ) 1.79 ( ) 1.79 ( ) Aged yrs 1.54 ( ) 1.39 ( ) 1.36 ( ) Aged 55+ Reference Reference Reference Men 1.31 ( ) 1.78 ( ) 1.74 ( ) women Reference Reference Reference Married Reference Reference Reference Previously married 1.56 ( ) 1.69 ( ) 1.60 ( ) Never married 1.58 ( ) 1.64 ( ) 1.54 ( ) Not covered by health plan 2.31 ( ) 3.09 ( ) 2.89 ( ) Covered by health plan Reference Reference Reference Self-rated fair/poor Health 1.76 ( ) 1.50 ( ) 1.46 ( ) Self-rated good/excellent Health Reference Reference Reference With disability 2.54 ( ) 1.76 ( ) 1.74 ( ) Without disability Reference Reference Reference Smoker 1.28 ( ) 1.15 ( ) 1.14 ( ) Former smoker/never smoked Reference Reference Reference Physically active in leisure time Reference Reference Reference Physically inactive in leisure time 1.32 ( ) 1.47 ( ) 1.44 ( ) Had dramatic brain injury 1.66 ( ) 1.12 ( ) 1.10 ( ) No dramatic brain injury Reference Reference Reference

19 Discussions We identified two latent class variables that are associated with suicidal thoughts -Being a member of lower socioeconomic class -Being a member of mentally unhealthy class

20 Discussions We also identified several individual risk factors that are associated with suicidal thoughts: No healthcare coverage Self-rated poor/fair health status Based on our knowledge, they have not been reported in the literature.

21 Discussions Strength of the analysis: - Examined the likelihood of being a member of lower socioeconomic class and mentally unhealthy class - Using these valid latent class variables as independent variables to identify potential indicators of the suicidal thoughts - Modeling results indicate that being a member of lower socioeconomic class or of mentally unhealthy class is more likely to report suicidal thoughts

22 Discussions Strength of the analysis: Latent class variable modeling approach counted for the correlation and overlap among individual suicide risk factors Overcame some of the limitations from the singleindicator modeling approaches Filled some information gaps about suicidal thoughts among old-aged veterans and active military: Majority of the respondents (60%) in this analysis were aged 55 years old or above and recent publications only focused on younger veterans and active military

23 Discussions Limitations of the analysis: selection bias: -Those with no phone were not included -Those who were institutionalized due to very poor mental health status Recall bias: -Self-reported data Social desirability bias -Very sensitive question was asked Cross sectional analysis: - Cause-effects relationship should not be inferred

24 Conclusions Our latent-class modeling approach has identified that socioeconomic and mentally unhealthy status among adults are strongly associated with suicidal thoughts. Suicide prevention programs should focus on adults in this group. It may also be useful in identifying other potential risk factors that are difficult to do so by the conventional single-indicator modeling approaches.

25 Thanks To your attention To all of my coauthors: Chaoyang Li, MD, PhD Guixiang Zhao, MD, PhD Alexander E. Crosby, MD Matthew M. Zack, MD, MPH Lina Balluz, Sc.D. MPH

26 Contact Information John Wen Environmental Health Tracking Branch Division of Hazards and Health Effects National Center for Environment Health Centers for Disease Control and Prevention