Our results suggest that both the category and severity of the mental disorder are associated with initial and subsequent mammography for insured women with mammography benefits. Women with anxiety, mood, psychotic, and substance disorders were at the greatest risk for not receiving mammography. Women with high-severity mental disorders were the least likely to have received mammography. Furthermore, the severity of mental disorders was also associated with not receiving a second mammogram.
The effect of adjusting for important confounders is highlighted by these analyses. The unadjusted rates show that women with low-severity mental illness were actually more likely to have received mammography than women without mental disorders. This finding supports Druss's14
observation that persons with mental illness have to have more visits
to primary care providers to receive similar levels of preventive services. In this work, controlling for nonmental health utilization diminishes receipt of mammography. We were unable to control for mental health utilization, given that the controls had no such utilization. However, we noted that although mental health visits linearly increased with severity, severity remained an independent predictor of low receipt of mammography. It is unlikely, therefore, that mental health contact played an important role in receipt of mammography.
The severity measure chosen for this study was based on the need to blend the best specification of mental disorder category, with overall intensity of care. This was done by selecting the diagnostic category (e.g., mood disorders) based on clinical prominence, and considering that inpatient visits and comorbid substance abuse likely suggested higher severity with regard to utilization and treatment outcomes. Substance abuse has been shown to frequently be secondary to other primary mental disorders.24
Other considerations of severity were not selected for a variety of reasons. We did not look at overall number of outpatient visits, given that few visits may represent either appropriate therapy for less severe cases or inappropriate therapy if the need was actually greater. A greater number of outpatient visits may actually suggest that persons were receiving psychotherapy, in addition to medication checks, which may only reflect treatment preference. Moreover, outpatient visits to specialists (e.g., cardiologists) would not be expected to relate to receipt of mammography. Thus, only outpatient visits to primary care providers and ob/gyns were considered as these visits are the most likely to influence receipt of mammography.
This study cannot answer why mental illness is associated with receipt of mammography for women with similar insurance coverage for mammography. We speculate that several factors may be salient. First, patients with mental disorders, especially those with more severe mental illness, may have difficulty navigating the medical system.25–27
Reasons may include difficulty in communicating with health care providers, poorly integrated medical and psychiatric care, and patient uncertainty regarding the availability of care.28
The negative stigma of mental disorders may affect providers' care for persons with these conditions.29
Competing demands posed by patients with mental disorders may preclude provider opportunities to address preventive care. Finally, we do not know from this study whether women with mental disorders were offered or scheduled mammography and did not report for testing. This issue may be related to the literature on compliance,17,30–34
especially in women with depression, anxiety, and psychotic disorders and merits additional study. In addition, fear or anxiety about the results of mammography may prevent some women from undergoing screening.35,36
Barriers such as embarrassment, or fear of being treated rudely may also be prohibitive.8,13
Other limitations should be noted. Our sample included insured women from Iowa, a racially homogeneous state limiting generalization of the results to uninsured and ethnically diverse populations. Second, women who did not visit health care providers during the study period could not be analyzed as we relied on claims data. It is not known whether these women were more or less likely to have mental disorders compared with women in the study. Physicians' failure to bill for services or subjects with multiple insurers may have resulted in underreporting. Mental disorders may be undercoded in claims data, either because physicians do not recognize the mental disorder, or because patients are apprehensive about a mental disorder appearing in their medical records.37
Third, differences in length of observation and women with more than 1 mental disorder being classified into a single category based on clinical prominence may have affected the results. Finally, we considered women with mental disorder claims and looked both retrospectively and prospectively for receipt of mammography; thus, we could not determine a cause (mental disorder) and effect (receipt of mammography) relationship. However, the assumption of cause and effect does not take into account the chronic and episodic nature of many mental disorders and that women may have been having disorders before claims. Using claims data can only establish associations.
The strengths of this study are important to note. This large population-based study considered both the type and severity of the mental disorder, prior utilization, and rural dwelling among women with the same insurance benefits for mammography in a fee-for-service environment (less than 10% were in managed care plans). Contrary to studies evaluating the mammography experiences of women in single clinic systems, this study supports results from prior studies indicating that delivery of mammography is negatively affected by the presence of a mental disorder. Although a large percentage of women in our sample had claims for mental disorders during the years under study, this is consistent with the National Comorbidity Survey (47% of women had any lifetime mental disorder), and work performed by the World Health Organization.38,39
If type and severity of mental disorders affect the delivery of medical services, what are the next steps that should be taken? Models of care include delivery in the inpatient setting, integrated outpatient services, or the assumption of principal medical care by mental health specialists.40
Inpatient delivery is supported by recent literature evaluating medical service utilization in substance users,41,42
and patients enrolled in integrated mental health/primary care clinic were more likely to receive 15 of 17 preventive services and report improvement in self-reported physical quality of life.43
Integrated women's health clinical and mental health services are associated with favorable utilization of Pap smears and breast examinations.8
Principal care models have been developed in community mental health centers and in the Veterans Administration to address the medical needs of individuals with mental disorders. Although mental health providers may take the lead in ordering preventive services or in delivering specialty care while addressing mental health needs (e.g., HIV/AIDS care), those services requiring special equipment (e.g., mammography or colonoscopy) may not be readily available in these settings.44–46
In summary, women with anxiety, mood, psychotic, and substance disorders represent an at-risk group for failure to receive mammography. Attention should be paid to these women, especially those with more severe mental illness or those without a source of primary medical care. This work highlights the need for integrated and targeted systems of medical and psychiatric care. In addition, future studies are needed to assess the role of organizational, provider, or patient characteristics in lower rates of services received by women with mental disorders.