Part II: Special Topics

Dual Diagnosis Stays

A person with both a substance-related problem and a mental health disorder is considered to have a dual diagnosis. According to studies cited in the Surgeon General's Mental Health Report,¹ nearly half of individuals with serious mental illness have associated alcohol or drug-related problems. For successful treatment, both problems must be addressed.

• In 2004, over 1 million adult hospital stays were related to both substance-related disorders and mental health disorders (3.1 percent of all adult hospital stays).
• Approximately 13 percent of the 7.6 million MHSA-related hospital stays involved both substance-related disorders and mental health disorders.
• Among hospital stays with a dual diagnosis, 64 percent had a principal and secondary MHSA diagnosis (44.9 percent with a principal mental health disorder and secondary substance abuse disorder, 19.2 percent with a principal substance abuse disorder and secondary mental health disorder). The remainder had a non-MHSA principal diagnosis and had both mental and substance abuse disorders as secondary diagnoses (35.9 percent).
• Among dual diagnosis stays, 34 percent of patients had alcohol-related disorders, 45 percent had drug-related disorders, and 22 percent had both alcohol and drug-related disorders.
• The most frequent mental health disorder associated with substance-related disorders was mood disorders (67.8 percent). All other mental health disorders occurred less frequently. Anxiety disorders and schizophrenia were seen in about 19 percent and 18 percent, respectively, of dual diagnosis stays.

Select for Figure 21. (7 KB), Dual MHSA Diagnosis: Principal and Secondary Diagnoses.

Select for Figure 22. (6 KB), Dual MHSA Diagnosis Stays: Type of Substance Abuse Disorder.

Table 8. Dual Diagnosis Stays for All-Listed MHSA Diagnoses

All-Listed Mental Health Diagnoses	Total Number of Hospital Stays	Percentage of all Dual Diagnosis Hospital Stays
Mood disorders including bipolar disorders and depressive disorders	679,336	67.8
Anxiety disorders	187,148	18.7
Schizophrenia and other psychotic disorders	183,584	18.3
Personality disorders	121,783	12.2
Miscellaneous mental disorders	66,231	6.6
Delirium, dementia, and amnestic and cognitive disorders	52,098	5.2
Adjustment disorders	33,619	3.4
Disruptive behavior disorders	16,013	1.6
Impulse control disorders	8,046	0.8
Disorders usually diagnosed in infancy, childhood, and adolescence	1,095	0.1

Note: “All-listed mental health diagnoses” refers to all mental health diagnoses listed on the discharge record; a patient can have more than 1 mental health diagnosis.

Gender and Age

• Men accounted for disproportionately more dually diagnosed inpatient stays than women. Although 38 percent of non-MHSA stays and 41 percent of other MHSA stays were for men, 55 percent of stays with dual diagnosis were for men.
• Most dually diagnosed inpatients were younger. Patients ages 18-44 accounted for nearly 60 percent of all dual diagnosis stays, even though these patients comprised only 26 percent of other MHSA stays and 33 percent of non-MHSA hospital stays.

Select for Figure 23. (11 KB), Dual Diagnosis Hospital Stays, by Gender and Age.

Expected Primary Payer

• Uninsured stays and hospital stays billed to Medicaid were disproportionately more likely to include both mental health and substance abuse diagnoses. Over 14 percent of dual diagnosis stays were uninsured—nearly three times higher than the rate for non-MHSA stays (4.9 percent) and over two times higher than the rate for other MHSA stays (6.7 percent).
• Similarly, nearly 32 percent of dual diagnosis stays were billed to Medicaid, while 15 percent of other MHSA stays and 13 percent of non-MHSA stays were billed to Medicaid.
• Medicare was billed for smaller proportion of dual diagnosis stays than other MHSA or non-MHSA stays, consistent with the findings on age.

Select for Figure 24. (11 KB), Dual Diagnosis Hospital Stays, by Expected Primary Payer.

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Suicide-Related Stays

Suicide is the cause of death for approximately 30,000 people each year in the United States,⁵ but many more attempts are unsuccessful and result in hospitalization. Although men are 4 times more likely to die from suicide, women are 3 times more likely to attempt suicide. Most suicide deaths result from the use of firearms. Known risk factors for suicide include a history of mental disorders (predominately depression) and a history of alcohol and substance abuse.

• In 2004, nearly 179,000 adult hospital stays were related to suicide or suicide attempts.
• By far, the most frequent mechanism of injury for suicide-related hospitalizations was poisoning. Nearly two-thirds (61.1 percent) of hospital stays for suicide attempts were a result of poisonings, while 1 in 10 hospital stays for suicide attempts was a result of cutting/piercing. Firearms were implicated in only 1 percent of suicide-related hospital stays.
• Nearly all suicide-related hospital stays were related to MHSA disorders (92.6 percent).
• The single most common MHSA diagnosis related to attempted suicide was mood disorders, which accounted for nearly 70 percent of all suicide-related stays. Other common MHSA diagnoses included substance-related disorders (49.1 percent), anxiety disorders (15.5 percent), personality disorders (10.9 percent), and schizophrenia (9.1 percent).
• Although personality disorders and adjustment disorders were uncommon in all MHSA hospital stays (less than 1 percent), they accounted for about 11 and 7 percent of suicide-related stays, respectively.

Select for Figure 25. (7 KB), Suicide-Related Hospital Stays, by Type.

Table 9. Mechanism of Injury for Suicide-Related Stays

All-Listed Mechanism of Injury	Total Number of Hospital Stays	Percentage of all Suicide-Related Hospital Stays
Poisoning	143,512	61.1
Cut/pierce	23,298	9.9
Firearm	2,900	1.2
Suffocation	2,173	0.9
Fall	1,834	0.8

Note: “All-listed mechanisms of injury” refers to all external cause of injury codes (e-codes) listed on the discharge record; a patient can have more than 1 e-code or mechanism of injury.

Table 10. Suicide-Related Stays for All-Listed MHSA Diagnoses

All-Listed MHSA Diagnoses	Total Number of Hospital Stays	Percentage of all Suicide-Related Hospital Stays
Mood disorders including bipolar disorders and depressive disorders	124,519	69.7
Substance-related disorders including drug and alcohol abuse disorders	87,768	49.1
Anxiety disorders	27,734	15.5
Personality disorders	19,419	10.9
Schizophrenia and other psychotic disorders	16,324	9.1
Adjustment disorders	12,092	6.8
Miscellaneous mental disorders	3,770	2.1
Disruptive behavior disorders	2,583	1.5
Delirium, dementia, and amnestic and cognitive disorders	1,633	0.9
Impulse control disorders	1,440	0.8
Disorders usually diagnosed in infancy, childhood, and adolescence	332	0.2

Note: “All-listed MHSA diagnoses” refers to all MHSA diagnoses listed on the discharge record; a patient can have more than 1 MHSA diagnosis.

Gender and Age

• Women accounted for disproportionately more hospital stays of all kinds—57 percent of stays related to suicide attempts, 58 percent of stays for non-suicide-related MHSA disorders, and 62 percent of non-MHSA stays.
• The mean age for adults hospitalized for suicide attempts was about 30 years, compared with 46 years for all other patients (data not shown).
• The majority of hospital stays for suicide attempts occurred among patients ages 18-44 (71.6 percent), followed by patients 45-64 (24.4 percent). Inpatients in the older age categories, 65 and older, made up less than 4 percent of all stays for suicide.
• Although adults ages 18-44 accounted for 72 percent of suicide-related stays, they accounted for only 29 percent of other MHSA stays and 33 percent of non-MHSA stays.
• Among the 45-64 age group, the rate of hospitalizations related to suicide attempt was consistent with the rate of all other hospitalizations.
• In contrast, patients 65 to 79 years of age accounted for only 3 percent of suicide-related hospital stays while they accounted for 20 percent of MHSA stays and 26 percent of non-MHSA stays. Similarly, only 1 percent of suicide-related stays were for patients 80 and older.

Select for Figure 26. (11 KB), Suicide-Related Hospital Stays, by Gender and Age.

Expected Primary Payer

• Uninsured stays and stays billed to Medicaid made up nearly half of all suicide-related hospitalizations. Even though only 5 percent of non-MHSA hospital stays were uninsured, 22 percent of suicide-related stays were uninsured. Nearly 13 percent of non-MHSA hospital stays were billed to Medicaid compared with 23 percent of suicide-related stays.
• Disproportionately fewer suicide-related stays were billed to Medicare (16.1 percent) compared with all other payers.
• Private insurance was billed for 32 percent of suicide-related stays, 37 percent of non-MHSA stays, and only 22 percent of MHSA stays unrelated to suicide attempt.

Select for Figure 27. (10 KB), Suicide-Related Hospital Stays, by Expected Primary Payer.

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Maternal Stays

There is evidence of unmet need among pregnant women with mental health disorders. Some studies suggest that mental illness in pregnancy is underdiagnosed and undertreated. Substance abuse, depression, and high levels of stress are associated with high risk behavior, preterm birth, and poor pregnancy outcomes.

Certain conditions, such as depression and eating disorders, are more common in women and can worsen during pregnancy. It has been suggested that 5 to 25 percent of women experience depression during pregnancy or immediately following birth, and that most of these women go untreated.^6-7 Examining maternal hospitalizations associated with MHSA disorders can provide insight into the problem, although it is likely that MHSA disorders will be underreported in hospital data.

• In 2004, nearly 4.6 million hospital stays occurred for women with maternal conditions. Of these, 240,000 (5.2 percent) involved at least one MHSA diagnosis.
• The top ranked MHSA diagnosis was “miscellaneous mental disorders” which includes “other conditions in the mother classifiable elsewhere, but complicating pregnancy” (ICD-9-CM code = 648.4x). Specifically, “mental disorders during delivery” accounted for 173,900 cases, “mental disorders before delivery” accounted for 30,000 cases, and “mental disorders following delivery” accounted for 5,700 cases.
• Mood disorders were seen in 77,000 maternal stays (1.7 percent). There were nearly 60,000 maternal hospital stays that included some mention of substance-related disorders (1.3 percent). Over 21,000 maternal stays had a complicating diagnosis of anxiety disorders (0.5 percent) and over 4,000 maternal stays also had a diagnosis of schizophrenia (0.1 percent).

Select for Figure 28. (7 KB), Maternal Hospital Stays, by Type.

Table 11. Maternal Stays for All-Listed MHSA Diagnoses

All-Listed MHSA Diagnoses	Total Number of Hospital Stays	Percentage of all Maternal Hospital Stays
Miscellaneous mental disorders	214,272	4.7
Mood disorders including bipolar disorders and depressive disorders	77,490	1.7
Substance-related disorders including drug and alcohol abuse disorders	58,935	1.3
Anxiety disorders	21,511	0.5
Schizophrenia and other psychotic disorders	4,074	0.1
Adjustment disorders	3,147	0.1
Personality disorders	1,884	0.0
Disruptive behavior disorders	1,065	0.0
Delirium, dementia, and amnestic and cognitive disorders	195	0.0
Impulse control disorders	109	0.0
Disorders usually diagnosed in infancy, childhood, and adolescence	192	0.0

Note: “All-listed MHSA Diagnoses” refers to all MHSA diagnoses listed on the discharge record; a patient can have more than 1 MHSA diagnosis. “0.0” percent indicates < .05 percent.

Age

• Women with MHSA disorders complicating a maternal stay were disproportionately younger, ages 18-24. Although this group accounted for 32 percent of non-MHSA-related maternal stays, they were responsible for 40 percent of all MHSA-related maternal stays.
• Women ages 25-34 accounted for almost half of maternal stays complicated by MHSA disorders (46.3 percent) and over half of all non-MHSA related maternal stays (52.1 percent).
• Women age 35 and older accounted for nearly 14 percent of maternal stays complicated by MHSA disorders and 16 percent of non-MHSA related maternal stays.

Select for Figure 29. (9 KB), Maternal Hospital Stays, by Age.

Expected Primary Payer

• Medicaid was much more likely to be billed for maternal stays complicated by MHSA disorders. Medicaid was billed for 38 percent of maternal stays with no MHSA disorders, but almost 57 percent of maternal stays with MHSA disorders.
• Private payers were disproportionately less likely to be billed for maternal stays associated MHSA diagnoses. Private insurance was billed for 56 percent of maternal stays with no MHSA disorders, but only 35 percent of maternal stays with MHSA disorders.

Select for Figure 30. (9 KB), Maternal Hospital Stays, by Expected Primary Payer.

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