Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

Improving the Mental Health of Women Recognition and Treatment of Depression

WHITNEY P. WITT:  Good morning.  It's nice to see all of you here.  Today I'm going to talk about a study that's part of a larger group of studies.  This offshoot is entitled, "Psychological Distress and Timely Use of Routine Care, the Importance of Having Health Insurance in a Usual Source of Care for Women with Children."  I want to just first acknowledge the other contributors to this study; namely, Timothy Ferris, Lisa Fortuna, who's here with us today, Robert Kahn, Karen Kuhlthau, Paul *Peracula, and Jonathan Winickoff.  Today I'm going to walk you through the background of what we discovered about what's been done in this area, the methods that we used, some results, and summary conclusions, and then the strengths and limitations of this study and what policy implications there may be.  So we know that having health insurance and a usual source of care facilitates healthcare use, and actually not having a usual source of care is often a stronger predictor of delays in care than health insurance. 

And we know that having a usual source of care is associated with increased use of preventive services in adults, particularly around cancer screening in women.  However, the use of preventive services for women has really not been examined in the context of psychological distress, and there're really no studies on women with children.  So we really don't have a very good sense of the impact of maternal psychological distress on preventive healthcare practices and service use in the family.  And the reason why this is important is because if mom is not taking care of herself, then-- and she gets sick, because she's not going to be able to take care of her kids.  And so that was one of the reasons why we thought this was an important area to explore further.  So the aims of this study were to understand the relationship between maternal psychological distress, health insurance status, and having a usual source of care, with the use of routine care among women with children. 

We hypothesized that maternal psychological distress would be associated with delays in routine care and that the absence of a usual source of care and no health insurance would be associated with delays in routine care.  So, again, just to sort of go back to what I was talking about before, that this is part of a larger group of studies looking at the impact of maternal psychological distress on the family, I just wanted to sort of give you a sense of where this fits into the larger body of work that we have been working on.  So what we're really interested in is looking at maternal psychological distress, how it affects prevention practices in the family, so we have a number of studies on seatbelt use and guns in the home, smoking, and also looking at health and mental health status and then healthcare use.  So just to give you a sense of this study, we're focusing on the mother only in this study and the health and mental-- her health and mental health status and her use of routine care.  So our sample consisted of about a little over 5,800 mothers between the ages of 18 to 49.  We used the National Health Interview Survey from 1998, the Adult Prevention Module, to gather the variables and questions that we used in the study. 

The main independent variable in this study is maternal psychological distress, and this was measured by a six-item distress battery that was created by Ron Kessler and colleagues.  It's called the Kessler Six, and it's now embedded in the National Health Interview Survey.  And we categorized mothers with psychological distress if they had mild to moderate distress, and this was a score of seven out of a possible 24.  In terms of health insurance status, we examined whether or not they had health insurance at all versus none.  In terms of usual source of care, we looked at a two-level variable.  First, we looked to see if they had a usual source of care and where they got it.  So if they said, "Yes, I have a usual source of care," and they reported that they had received their care in a clinic, health center, doctor's office, health maintenance organization, hospital outpatient department, or some other place, then they were considered to have a usual source of care.  If they reported that they had received their care at an emergency room, they were considered to not have a usual source of care.  So our main dependent variable in the study was gathered from this question:  "About how long has it been since your last general physical exam or routine check-up by a medical doctor or other health professional?"  This did not include visits for health problems.  This was just general routine exam.  The responses included:  "Never; a year ago or less; more than one year but not more than two years; more than two years but not more than three; and more than three years but not more than five; and over five years ago." 

In this study, we excluded mothers who reported that they had never received routine care because there were so few of them that had reported that.  Only about 300 women out of our sample reported that they had never received a physical exam, and there're very-- we also looked at the socio-demographic characteristics of these women, and they were very, very different than the ones who reported that they had ever gotten a routine physical exam.  So what we did was we modeled the odds of mothers having received routine care two or more years ago, and this was considered delayed care, against mothers who received care as recently as a year ago or less but not more than two years.  And we picked this cut point because we actually went to the literature to try and find out if there were any guidelines about how often women should get routine physical exams, and there aren't any.  There are no guidelines at all.  All the guidelines are around specific diagnostic tests, like Pap smears or mammograms or breast exams, but not around how often one should receive a physical exam, and this is for men and women.  So what we decided was that, based on the clinical expertise of our research team and talking with other family physicians and primary care providers, we decided that we probably-- most women would probably need to see a physician once a year, and then we, because of recall bias, we decided to extend that to two years since this is a self-reported survey and we wanted to be conservative in allowing people to remember when they had their last physical exam. 

So in this analysis, we controlled for maternal age, education, race ethnicity, health status, current pregnancy status, whether or not they were single parents, poverty, and region of family residence.  So here are the results.  Almost 13 percent of the mothers reported psychological distress, and these mothers were more likely to be younger, have a lower level of education, be Hispanic and single parents living in poverty, compared with other mothers, and there were no differences by region of the U.S. or whether or not they were currently pregnant.  What this table shows you is the mothers' health insurance and usual source of care status by psychological distress.  And what you see in the left-hand column is mothers who reported having psychological distress, and what we see here is that mothers who reported distress were more likely to also report that they did not have health insurance, 23.2 percent versus 15.0 percent.  And, similarly, we found that these women also reported-- were more likely to report that they did not have a usual source of care, 16.1 percent versus 9.4 percent.  When we look at mothers receiving delayed routine care by distress status, we found that mothers with distress were more likely to report that they had received delays in their routine care, 26.6 percent versus 21.4 percent.  This is statistically significant; however, you know, there's not much of a difference. 

So in terms of clinical difference, that may be a question.  So in our final model-- this is controlling for all the variables that I had mentioned before-- what we found was that for the odds of delayed routine care that mothers with psychological distress were 1.2 times more likely to report delays in routine care.  If they did not have health insurance, the odds went up, it was 1.6.  And the strongest corollary of reporting delays in routine care was not having a usual source of care, at 3.2, and these are all statistically significant.  One of the things we wondered about is whether or not there was possibly an interaction between psychological distress and health insurance status and having a usual source of care, and so we tested this hypothesis to see if, in fact, those women who were distressed and didn't have health insurance or women who were distressed and didn't have a usual source of care were even more likely to have delays in their routine care.  And what we found was that there was not an interaction between distress and health insurance, but there was an interaction between maternal distress and having a usual source of care.  And, basically, this table shows you that. 

And, again, this is controlling for all of the variables that I'd spoken about earlier.  And, basically, what we found was that mothers with distress who did not have a usual source of care were almost six times more likely to report that they had delays in routine care compared with only 2.8 of mothers without distress who did not have a usual source of care.  We did test this for interaction.  We tested the model with and without an interaction term using the likelihood ratio test, and we found that this interaction term did significantly contribute to the model, indicating that the interaction was significant.  So, in summary, after controlling for potential confounders, we found that maternal psychological distress, health insurance, and having-- not having a usual source of care were all associated with delays in routine care for mothers and that mothers with psychological distress and an appropriate usual source of care were no more likely to delay their care than other mothers. 

However, the mothers who reported distress and did not have a usual source of care were almost six times more likely to report delays in receiving a physical exam, and this was statistically significant, as I mentioned before.  So the strengths of the study is that it really provides some national estimates about moms' psychological distress and access to primary care, and this is really the first study to examine the correlates of the use of routine care for mothers in the context of psychological distress.  However, there are potential limitations I should mention.  The timing of the relationship between the usual source of care and the report of receiving routine care can't be determined from this study because this is a cross-sectional study, so we can really only examine correlations, not causation.  But I think that this study does provide a nice foundation for, hopefully, investigators to further this work and do some longitudinal work to really try and tease out this relationship.  And there is the possibility that individuals who use more care were more likely to report a usual source of care, so that's another potential limitation. 

So in terms of policy implications, there seems to be a need for having a usual source of care, continuity of care, for mothers with psychological distress.  And the reason why this is especially important is that these moms, if they're not interfacing with the healthcare system in a timely manner, are likely to go unscreened for important, preventable, and treatable conditions, including mental health problems.  And this has significant implications, as we all know, about the impact of psychological distress and mental health problems on children.  If moms are not getting screened and not getting timely routine care, then that exposes the kids to her problems and potentially opens them up for-- and puts them at risk for developing mental health problems themselves.  So that's it.  Thank you very much.