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Datapoints: Trends in Mortality Among Homeless VA Patients With Severe Mental Illness
Denis G. Birgenheir, Ph.D.; Zongshan Lai, M.P.H.; Amy M. Kilbourne, Ph.D., M.P.H.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201300026
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The authors are affiliated with the Department of Veterans Affairs Ann Arbor Health Center for Clinical Management Research. Send correspondence to Dr. Kilbourne at North Campus Research Complex, 2800 Plymouth Rd., Ann Arbor, MI 48108 (e-mail: amykilbo@med.umich.edu). Dr. Kilbourne and Tami L. Mark, Ph.D., are editors of this column.

Copyright © 2013 by the American Psychiatric Association

Both homelessness and severe mental illness are known to increase the likelihood of early mortality. We determined years of potential life lost (YPLL) over an 11-year period among Department of Veterans Affairs (VA) patients using homeless services, assessing for the impact of severe mental illness.

Using the VA National Patient Care Database (NPCD), we analyzed all-cause mortality for fiscal years (FYs) 2000–2009 among VA patients by severe mental illness status and use of VA homelessness services for each FY. All patients with a severe mental illness diagnosis from each FY were identified by ICD-9 codes. We also used NPCD data to identify a 5% random sample of individuals without a severe mental illness diagnosis for each FY. The primary analyses were hazard ratio calculations on all-cause mortality, comparing differences in YPLL adjusted for age and gender by homelessness and severe mental illness status.

Regardless of severe mental illness diagnosis, homeless veterans died younger than nonhomeless veterans in all years, with YPLL ranging from 18.9 to 24.3 (Figure 1). For nonhomeless veterans with and without severe mental illness, YPLL ranged from 9.1 to 14.0 years. Homeless veterans with severe mental illness had the greatest YPLL over time. Nonhomeless veterans with severe mental illness died younger than those without a severe mental illness. Using time-series analyses, we found a statistically significant increase in YPLL only for nonhomeless veterans without severe mental illness.

 
Anchor for JumpAnchor for Jump
Figure 1Years of potential life lost (YPLL) from all-cause mortality among veterans (N=575,194), by homelessness and severe mental illness (SMI) statusa

a SMI: inpatient or outpatient ICD-9 code for schizophrenia, bipolar disorder, or other psychosis. Homelessness: outpatient or inpatient service code ICD-9 V60.0 (lack of housing) or clinic stop code 501 or 528 (homeless mentally ill outreach), 522 or 530 (Housing and Urban Development–Veterans Affairs Supported Housing initiative), 529 (health care for homeless veterans), 590 (community outreach for homeless veterans), or inpatient homeless stay (37, domiciliary; 28, homeless compensated work therapy)

Overall, having a severe mental illness diagnosis increased YPLL regardless of housing status. Homelessness was an additional and more severe contributor to YPLL, above and beyond a severe mental illness diagnosis. Thus, in this study, homelessness had the strongest effects on YPLL. However, VA patients who were not homeless and who did not have a severe mental illness diagnosis were also dying younger over time. The VA has made ending homelessness among veterans a priority, with a particular focus on those with severe mental illness. Recent VA efforts to help homeless veterans and integrate services for those with severe mental illness may have offset this trend for these vulnerable populations. Further research is needed to assess the long-term impact of emerging initiatives, such as medical home models for homeless veterans and those with severe mental illness, on reducing the mortality gap.

This work was supported by the Health Services Research and Development Service (IIR 11-232), Veterans Health Administration. The views expressed are those of the authors and do not necessarily represent the views of the VA.

The authors report no competing interests.

Figure 1 Years of potential life lost (YPLL) from all-cause mortality among veterans (N=575,194), by homelessness and severe mental illness (SMI) statusa

a SMI: inpatient or outpatient ICD-9 code for schizophrenia, bipolar disorder, or other psychosis. Homelessness: outpatient or inpatient service code ICD-9 V60.0 (lack of housing) or clinic stop code 501 or 528 (homeless mentally ill outreach), 522 or 530 (Housing and Urban Development–Veterans Affairs Supported Housing initiative), 529 (health care for homeless veterans), 590 (community outreach for homeless veterans), or inpatient homeless stay (37, domiciliary; 28, homeless compensated work therapy)

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