Pathological gambling, co-occurring mental health and substance use disorders:

An Assessment of the Provision of Care by Clinician Specialty

Rosa Rodriguez-Monguio, PhD, MS

Maria Errea, PhD

Rachel Volberg, PhD

APHA Atlanta, GA. November 8, 2017

Presenter Disclosures

Authors declare that they have no competing interests

Outline

Background

Objectives

Data and Methods

Results

Conclusions

Background

Pathological gambling is an impulse control disorder concurrent with other psychiatric and substance use disorders

Little is known about treatment-seeking behaviors in patients with diagnosis of pathological gambling and co-occurring clinical disorders and associated treatment provision

Objectives

Assess socio-demographic characteristics of patients seeking treatment for pathological gambling and co-occurring substance use related addictions and mental health disorders

Analyze the workforce composition and geographic distribution of treatment providers

Estimate the likelihood of receiving care for psychiatric and substance use disorders by clinician specialty

Data

Massachusetts (MA) All-Payer Claims Database (APCD) for the period 2009-2013

Representative health claims database

Medical and pharmaceutical claims

All health care settings and levels of care

Physician/outpatient visits, inpatient and emergency department visits

Study Analytical Sample

Inclusion criteria

Commercially insured adult residents in Massachusetts who had a clinical diagnosis of pathological gambling (ICD-9-CM 31231) in any position any time in the study period and sought care in the Commonwealth

Exclusions: n = patients

Patients under 18 yrs.: n = 13

Patients (n= 8) providers (n= 2) zip code outside MA

Patients with public insurance only: n= 62

Patients whose first claim was in 2013: n=27

Methods

Analysis of the likelihood of receiving care for mental health and substance use disorders by clinician specialty Therapeutic providers: counseling psychologists, clinical social workers Prescribing providers: psychiatrists, general practice physicians

Univariate and multivariate logistic regression analysis controlling for age, gender, health insurance coverage and level of care - Adjusted Odds Ratios (AOR)

Multivariate logistic regression was conducted to estimate the likelihood of receiving care by assessed clinician specialties holding constant socio-demographic variables, type of health insurance coverage and level of care

Analyses performed with STATA MP 14 UMass Institution Review Board granted study approval

Patients Seeking Care in MA2009-2012

Diagnosis of PG in any position: 869 patients

71% males

27% aged 45-54 yrs.

25% Middlesex county

Private health insurance plans

47% Health Maintenance Organization (HMOs)

36% Preferred Provider Organization (PPOs)

13% Point of Service (POS)

Up to 4 co-occurring conditions 46% of patients

Patients with Diagnosis of PG Seeking Care in MA

407

492457 428

869

447

204229247204

373

185184193160

0

100

200

300

400

500

600

700

800

900

1,000

2009 2010 2011 2012 2009-2012

PG as Principal Diagnosis

PG as First Diagnosis

# Patients

PG in any Dx position

Most Prevalent Principal Diagnosis, 2009-2012

52%

30%

13%10%

6% 6%

0%

10%

20%

30%

40%

50%

60%

70%

Pathological

Gambling

Episodic

Mood

Disorders

Anxiety

Disorders

Psychoactive

Substances

Depressive

Disorders

Adjustment

Reaction

As a % of Patients with PG in Any Position N = 869

Psychoactive substances: Alcohol dependence syndrome (ICD9-code 303), drug dependence (ICD9-code 304) and non-dependent abuse of drugs (ICD9-code 305.0). Prevalence rates <3% were suppressed.

Most Prevalent Primary Diagnosis Pathological Gambling Principal

Diagnosis, 2009-2012

28%26%

18%

13%9%

0%

10%

20%

30%

40%

50%

Anxiety

Disorders

Episodic Mood

Disorders

Psychoactive

substances

Depressive

Disorders

Adjustment

Reaction

As a % of Patients with PG as Principal Dx N = 447

Psychoactive substances: Alcohol dependence syndrome (ICD9-code 303), drug dependence (ICD9-code 304) and non-dependent abuse of drugs (ICD9-code 305.0). Prevalence rates <3% were suppressed.

PG by MA County, 2009-2012

10%

7%

25%

14%

8%7%

10%12%

8%

13%11%11%

7%

23%

10%

8%

11%12%

12%

21%

5%

8%8% 8%

0%

10%

20%

30%

Bri

sto

l

Essex

Ham

pd

en

Mid

dle

sex

No

rfo

lk

Ply

mo

uth

Su

ffo

lk

Wo

rceste

r

Note: MA Counties ≤ 3% prevalence were suppressed

Patients Providers County Population

PG by Provider Specialty

PG as principal diagnosis significantly associated More than twofold likelihood of receiving care from

psychologists (AOR 2.8; p<0.01) and social workers (AOR 2.6; p<0.01)

Lower probability of receiving care from PCPs (AOR 0.40; p<0.01) and psychiatrists (AOR 0.37; p<0.01)

Depressive disorder diagnosis significantly associated with greater than three times likelihood of receiving care from PCPs (3.5; p<0.01).

PG by Provider Specialty

Having three diagnosis was significantly associated with a greater likelihood of receiving care from PCPs (AOR 2.9; p<0.01) and psychiatrists (AOR 4.7; p<0.01)

Having four or more diagnosis was significantly associated with a greater likelihood of receiving care from PCPs (AOR 5.6; p<0.001)

Limitations

Data through June 30, 2013

Right censored data

Pathological gamblers seeking care in MA

Underestimation of PG prevalence

Retrospective claims-based

Possible coding errors

Missing data for non-reimbursable variables

Conclusions

Anxiety disorders, mood disorders, and depressive disorders and psychoactive substance disorders are prevalent conditions in pathological gamblers

One in four treatment-seeking patients with a principal diagnosis of pathological gambling had a concurrent diagnosis of anxiety and mood disorders

One in five patients with a principal diagnosis of pathological gambling had a concurrent diagnosis of substance use disorders

Conclusions

Clinical complexity and prevalence of co-morbid psychiatric and substance use disorders among pathological gamblers seeking treatment

Unbalanced distribution and a shortage of mental health clinicians

Likelihood of receiving care by specialty clinicians significantly varied by comorbid disorder alone and as a bundle

Acknowledgements

Massachusetts Center for Health Information and Analysis (CHIA)

Funding provided by the Massachusetts Gaming Commission in Boston, MA

The findings, interpretations and conclusions expressed in this presentation are entirely those of the authors and do not represent the views of the Massachusetts Gaming Commission

Pathological gambling, co-occurring mental health and substance use disorders:

An Assessment of the Provision of Care by Clinician Specialty

Rosa Rodriguez-Monguio, PhD, MS

Maria Errea, PhD

Rachel Volberg, PhD

APHA Atlanta, GA. November 8, 2017