Psychological Distress and Access to Mental Health Services Among Cancer Survivors: a National Health Interview Survey A
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J Gen Intern Med DOI: 10.1007/s11606-020-06204-3 © Society of General Internal Medicine 2020
INTRODUCTION
Among cancer survivors, mental health conditions are responsible for a significant financial burden, accounting for the highest healthcare costs relative to other comorbid conditions.1 Furthermore, mental illness is associated with worse cancer-specific outcomes.2 Therefore, interventions addressing mental health interventions could improve oncologic outcomes2 and their associated healthcare costs. As such, we examined contemporary patterns of psychological distress and affordability of mental health service (MHS) among cancer survivors in the USA.
METHODS
The National Health Interview Survey (NHIS) collects data on health indicators in noninstitutionalized civilian adults living in the USA. For this study, harmonized data of participants self-reporting a cancer diagnosis from 2009 to 2018 were used. Sample weight-adjusted estimates of psychological distress were defined by the self-reported 6-item Kessler Psychological Distress Scale (K6). Using this index, K6 ≥ 13 is a validated binary threshold associated with severe mental illness;3 a 5-category scale has also been validated as follows: 0, 1–6, 7–12, 13–18, and 19–24 points.3 Additionally, the survey queried participants regarding whether they needed but were unable to afford MHS over the past 12 months. Multivariable logistic regression defined adjusted odds ratios (AOR) and 95% confidence intervals (95CI) for the odds of needing but not being able to afford MHS as the primary outcome and the five-level K6 psychological distress index as the primary independent variable of interest. The regression was repeated stratified by insurance status (insured vs. uninsured) and also stratified by socioeconomic status (defined as ratio of family income to poverty threshold (< 1.00 vs. 1.00– 1.99 vs. 2.00–3.99 vs. > 4.00)). For these stratified analyses, Received June 18, 2020 Accepted August 31, 2020
the primary independent variable of interest was psychological distress as a binary variable (K6 ≥ 13 vs. K6 < 13). In each of the logistic regression models, additional relevant demographic variables included are shown in Table 1. A separate model included a psychological distress (K6< vs. ≥ 13)*insurance status (insured vs. uninsured) interaction term to assess whether the effect of psychological distress on MHS affordability varied by insurance coverage.
RESULTS
Among 14,655 survivors of cancer, factors associated with needing but inability to afford MHS included younger age, female sex, lower socioeconomic status, uninsured status, and psychological distress (Table 1). For example, uninsured cancer survivors were more likely than their insured counterparts to report needing but being unable to afford MHS (15.5% vs. 2.0%, AOR 3.49, 95CI 2.47–4.92, p < 0.001). Increasing K6 score was also associated with needing but being unable to afford MHS among cancer survivors (trend p < 0.001) (Table 1, Fig. 1). Time from cancer diagnosis was not associated with difference
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