Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2014;95:2288-95

ORIGINAL ARTICLE

Racial/Ethnic Disparities in Mental Health Over the First 2 Years After Traumatic Brain Injury: A Model Systems Study Paul B. Perrin, PhD,a Denise Krch, PhD,b,c Megan Sutter, BA,a Daniel J. Snipes, MS,a Juan Carlos Arango-Lasprilla, PhD,d Stephanie A. Kolakowsky-Hayner, PhD,e Jerry Wright, MS,e Anthony Lequerica, PhDb,c From the aDepartment of Psychology, Virginia Commonwealth University, Richmond, VA; bKessler Foundation, West Orange, NJ; cDepartment of Physical Medicine and Rehabilitation, Rutgers-New Jersey Medical School, Newark, NJ; dIKERBASQUE Basque Foundation for Science, University of Deusto, Bilbao, Spain; eSanta Clara Valley Medical Center, San Jose, CA.

Abstract Objective: To determine whether racial/ethnic disparities occur in depression, anxiety, and satisfaction with life at 1 and 2 years postdischarge. Design: A prospective, longitudinal, multicenter study of individuals with traumatic brain injury (TBI) participating in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems project. Medical, demographic, and outcome data were obtained from the Model Systems database at baseline, as well as 1 and 2 years postdischarge. Setting: A total of 16 TBI Model Systems hospitals in the United States. Participants: Individuals with moderate or severe TBI (NZ1662) aged 16 years or older consecutively discharged between January 2008 and June 2011 from acute care and comprehensive inpatient rehabilitation at a Model Systems hospital. Intervention: Not applicable. Main Outcome Measures: The Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Satisfaction with Life Scale assessed depression, anxiety, and satisfaction with life at 1 and 2-year follow-ups. Results: After controlling for all possible covariates, hierarchal linear models found that black individuals had elevated depression across the 2 time points relative to white individuals. Asian/Pacific Islanders’ depression increased over time in comparison to the decreasing depression in those of Hispanic origin, which was a greater decrease than in white individuals. Black individuals had lower life satisfaction than did white and Hispanic individuals, but only marginally greater anxiety over time than did white individuals and similar levels of anxiety as did Asian/Pacific Islanders and Hispanic individuals. Conclusions: Mental health trajectories of individuals with TBI differed as a function of race/ethnicity across the first 2 years postdischarge, providing the first longitudinal evidence of racial/ethnic disparities in mental health after TBI during this time period. Further research will be required to understand the complex factors underlying these differences. Archives of Physical Medicine and Rehabilitation 2014;95:2288-95 ª 2014 by the American Congress of Rehabilitation Medicine

Traumatic brain injury (TBI) is a primary cause of death and disability in the United States1 and is the “hallmark injury” of military personnel deployed in the current wars in Iraq and Afghanistan.2 Approximately 1.7 million TBIs occur each year, leading to 53,000 deaths.1 Greater TBI impairments are associated with numerous functional problems, including difficulty maintaining Disclosures: none.

employment,3 marital instability,4 and psychological distress.5-7 Most individuals with TBI report depressive symptoms,8 and depressed individuals with TBI are more likely to experience comorbid anxiety,8,9 aggressive behavior, and suicidal ideation,10 as well as reduced executive functioning, social functioning,9 and satisfaction with life.6 Rehabilitation outcomes are associated with demographic and cultural characteristics. Being of a racial/ethnic minority and

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2014.07.409

TBI Racial disparities and mental health having TBI has been linked to reduced competitive employment,11 less engagement in leisure activities, less community integration,12 lower standard of living,13 lower likelihood of entering a rehabilitation facility after discharge from a trauma unit,14 and higher mortality rates.15 Compared with white individuals, at 1 year postdischarge black individuals report lower satisfaction with life16 and Hispanic individuals report greater depression.17 Among individuals without TBI, black and Hispanic individuals have a lower likelihood of receiving a depression diagnosis than do white individuals18,19; however, there remain disparities for these 2 groups in primary care for diagnoses, counseling/referrals, and prescription of antidepressant medication in the treatment of depression and anxiety.20 In addition, black and Hispanic individuals are less likely to report being very satisfied with their lives relative to their white counterparts.21 Although racial/ethnic disparities have begun to be documented, research has briefly explored differences in mental health and no studies have examined differences longitudinally. This study used hierarchal linear modeling to examine racial/ethnic differences in depression, satisfaction with life, and anxiety in a national sample of individuals with TBI at 1 and 2 years postdischarge.

Methods Participants Participants were from the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) national study, a multicenter longitudinal study assessing TBI outcomes.22 Participants met criteria for TBI, which includes trauma to the brain tissue owing to an external mechanical force as demonstrated by loss of consciousness, posttraumatic amnesia (PTA), or skull fracture, or objective neurological outcomes attributed to brain injury through physical or mental status examinations.22 Participants (1) had a self-reported race/ethnicity of white, black, Asian/Pacific Islander, or Hispanic origin; (2) had been 16 years or older at the time of injury; (3) had been admitted to 1 of the 16 TBIMS hospitals for acute care within 72 hours of injury for moderate or severe TBI; and (4) had been admitted to comprehensive inpatient rehabilitation at a TBIMS hospital.22 To be included in the current analyses, participants must have had data for at least 1 time point at either 1 year or 2 years postinjury for each mental health variable (depression, anxiety, and satisfaction with life). Participants had to have been hospitalized between January 15, 2008, and June 30, 2011, to be included because this is when the 3 mental health variables (Patient Health Questionnaire-9 [PHQ-9], Satisfaction with Life Scale [SWLS], and Generalized Anxiety Disorder 7-item [GAD-7] scale) were generally collected simultaneously across the TBIMS centers. For the current analyses, 1662 individuals met study criteria. See table 1 for a summary of the sample’s demographic characteristics.

List of Abbreviations: GAD-7 HLM PHQ-9 PTA SWLS TBI TBIMS

Generalized Anxiety Disorder 7-item hierarchical linear modeling Patient Health Questionnaire-9 posttraumatic amnesia Satisfaction with Life Scale traumatic brain injury Traumatic Brain Injury Model Systems

www.archives-pmr.org

2289 Table 1

Sample (NZ1662) characteristics

Characteristic Sex Male Female Missing Age at injury (y) Missing Marital status Single Married Divorced Separated Widowed Other Missing Annual earnings (US $) None 9,999 10,000e19,999 20,000e29,999 30,000e39,999 40,000e49,999 50,000e59,999 60,000e69,999 70,000e79,999 80,000e89,999 90,000e99,999 100,000 Missing Weekly paid competitive employment Missing Education (y) Missing Days in PTA Missing Glasgow Coma Scale score Missing

Value 1196 (72.0) 466 (28.0) 0 (0) 41.1018.74 0 (0) 762 565 205 50 76 2 2

(45.8) (34.0) (12.3) (3.0) (4.6) (0.1) (0.1)

561 (33.8) 184 (11.1) 164 (9.9) 159 (9.6) 141 (8.5) 97 (5.8) 84 (5.1) 61 (3.7) 30 (1.8) 21 (1.3) 22 (1.3) 78 (4.7) 60 (3.6) 30.0224.07 22 (1.3) 12.912.71 11 (0.7) 22.4120.77 217 (13.1) 11.514.00 18 (1.1)

NOTE. Values are n (%) or mean  SD.

The TBIMS database classifies race and ethnicity together using the following categories: white non-Hispanic, black non-Hispanic, Hispanic origin, and Asian/Pacific Islander. It should be noted that this categorization method is limited because it minimizes a very heterogeneous range of ethnicities. These categories are used for the present study because these were collected in this manner by the TBIMS and constitute the standard classification for data collection and research despite the potential lack of important nuance. There were 2 missing data points for marital status, 11 for education, 22 for weekly paid competitive employment (4 refused, 5 were missing, and 13 were unknown), and 60 for annual earnings (25 refused, 31 did not know, and 4 were missing). There were 217 missing data points for days in PTA (187 individuals were still unconscious or had amnesia at discharge and 30 had an unknown PTA score), and 18 data points were missing for the Glasgow Coma Scale23 score at admission. There were 122 missing data points for year 1 depression, 588 for year 2 depression, 120 for year 1 satisfaction with life, 590 for year 2 satisfaction with life, 612 for year 1 anxiety, and 584 for year 2 anxiety.

2290

Procedure Study procedures were approved by the individual institutional review boards for each funded TBIMS center. Participants, or when appropriate their legal guardian or family member, provided informed consent, and participants were recruited after admission to inpatient rehabilitation. If individuals with TBI were unable to provide data on demographic or preinjury characteristics, their caregiver or family member did so. Injury-related information was also obtained via medical records reviews. At year 1 and year 2 after injury, research assistants conducted follow-up interviews as part of a standard protocol.

Measures Patient characteristics Sociodemographic, preinjury, and injury-related characteristics, including race/ethnicity, age, sex, marital status, annual earnings, weeks in paid competitive employment in the year before injury, years of education, days in PTA, and Glasgow Coma Scale23 score at emergency department admission, were collected through selfreport and/or medical record review during inpatient rehabilitation stay. Patient Health Questionnaire-9 The PHQ-924 is a 9-item assessment of depression, where higher scores indicate greater depressive symptoms. The PHQ-9 has good test-retest reliability (rZ.84) and excellent internal consistency (aZ.86e.89).24 The PHQ-9 also has good criterion and construct validity, and good test-retest reliability in individuals with TBI.25 Satisfaction with Life Scale The SWLS is a 5-item assessment of life satisfaction,26 and higher scores indicate greater satisfaction with life. The scale has good test-retest reliability (rZ.82) and excellent internal consistency (aZ.87).26 The SWLS has good convergent validity with other measures of subjective well-being.27 The SWLS has been shown to be reliable and valid for use among individuals with TBI.28 Generalized Anxiety Disorder 7-item scale The GAD-7 scale is a 7-item measure of anxiety,29 on which higher scores indicate greater anxiety. The GAD-7 scale has good test-retest reliability (rZ.83) and excellent internal consistency (aZ.92).29 Although the GAD-7 scale has been used to assess anxiety symptoms among individuals with TBI,30 limited psychometric data are available for this population.

Data Analyses To evaluate the data’s degree of random missingness, a Little’s Missing Completely at Random test was performed with participants’ PHQ-9, SWLS, and GAD-7 scale scores and it was found that the data were missing completely at random, c2(37)Z45.37, PZ.16. Full information maximum likelihood provides an excellent strategy for managing missing data, especially when data are missing at random. Full information maximum likelihood works by estimating a specific likelihood function for each participant on the basis of all the data available for that participant. Therefore, hierarchical linear modeling (HLM), which uses full information maximum likelihood, was used to examine racial/ethnic differences in depression, satisfaction with life, and anxiety in individuals with TBI at year 1 and year 2 after hospital discharge.

P.B. Perrin et al A traditional approach in racial/ethnic health disparities research is (1) to document that health disparities exist and (2) to try to account for those disparities with demographic or injuryrelated differences among racial/ethnic groups. Therefore, these 2 steps were taken in the present study. In the first step, for each variable, 3 analyses were performed, which included orthogonal dummy codes (eg, 0 vs 1) of race/ethnicity, time, and the TimeRace/Ethnicity interaction. The first analysis for each mental health variable compared Hispanic, Asian/Pacific Islander, and black individuals with white individuals. The second compared Hispanic individuals and Asian/Pacific Islanders with black individuals. And the third compared Asian/Pacific Islanders with Hispanic individuals. All time effects are presented from the first analysis in each set, and for simplicity, the 3 separate analyses for each mental health variable are reported in a combined fashion. For the second step, this same series of analyses was then run with the inclusion of the following demographic and injury-related variables as covariates to determine whether these variables accounted for effects of race/ethnicity in the first analyses: age, PTA, sex, marital status, years of education, annual earnings, weeks in paid competitive employment during the past year, and Glasgow Coma Scale score at admission. As with time effects, all covariate effects are presented from the first analysis in each set.

Results Initial models without covariates Depression Participants’ mean depression scores at year 1 and year 2 broken down by race/ethnicity appear in figure 1 and table 2. HLM suggested that across the 4 racial/ethnic groups, there were no overall changes in depression between year 1 and year 2 (bZ.17; t [1740.07]Z.69; PZ.491). Black (bZ.89; t[2556.12]Z2.29; PZ.022) and Hispanic (bZ1.14; t[2608.85]Z2.09; PZ.037) individuals had higher depression across the 2 time points than did white individuals. Similarly, black (bZ 2.61; t[680.79]Z 2.72; PZ.007) and Hispanic (bZ 2.95; t[269.11]Z3.25; PZ.001) individuals had higher depression over time than did Asian/Pacific Islanders. However, Hispanic and black individuals had statistically similar depression (bZ.17; t[686.21]Z.27; PZ.787), as did Asian/Pacific Islanders and white individuals (bZ 1.43; t [2611.82]Z 1.61; PZ.109). The only significant interaction of Race/EthnicityTime was for the comparison of depression trajectory slopes between Hispanic individuals and Asian/Pacific Islanders (bZ 2.90; t[135.22]Z 2.55; PZ.012), suggesting that Asian/Pacific Islanders’ depression increased in comparison to a decrease in that of Hispanic individuals. Satisfaction with life As with depression, participants’ mean satisfaction with life at year 1 and year 2 broken down by race/ethnicity appear in figure 2 and table 2. HLM analyses suggested that there were no overall changes in satisfaction with life between year 1 and year 2 (bZ .41; t[1699.76]Z 1.28; PZ.199). Black individuals showed lower satisfaction with life over time than did white individuals (bZ 2.60; t[2519.61]Z 4.89; P

ethnic disparities in mental health over the first 2 years after traumatic brain injury: a model systems study.

To determine whether racial/ethnic disparities occur in depression, anxiety, and satisfaction with life at 1 and 2 years postdischarge...
434KB Sizes 0 Downloads 5 Views