C

Use of Cancer-Screening Services
Among Persons With Serious Mental
Illness in Sacramento County
Glen L. Xiong, M.D.
Richard A. Bermudes, M.D.
Serina N. Torres, B.A.
Robert E. Hales, M.D., M.B.A.
Objective: This study examined
the use of breast, cervical, colorectal, and prostate cancer–
screening services by persons
with serious mental illness enrolled in the Sacramento County
Mental Health clinics. Methods:
Of 387 outpatients approached
from January 2005 to May 2007,
229 were interviewed. Results:
Whereas 97% of the women had
received cervical cancer screening at least once in their lifetime,
more than 50% of eligible persons over age 50 had never received colorectal cancer screening. Recent use of screening services was highest for cervical cancer (69% had had a Pap test in the
past three years) and lowest for
colorectal cancer (12% had had a
fecal occult blood stool test in the
past year or a flexible sigmoidoscopy or colonoscopy in the
past five years). Conclusions:
Among persons with serious mental illness, lifetime screening of
cervical cancer was higher than
for breast, prostate, and colorectal cancers. Receipt of routine,
timely cancer screening was low,
especially for colorectal cancer.
(Psychiatric Services 59:929–932,
2008)
The authors are affiliated with the Department of Psychiatry and Behavioral
Sciences, University of California, Davis,
2230 Stockton Blvd., Sacramento, CA
95817 (e-mail: [email protected]).
PSYCHIATRIC SERVICES
C
ompared with the general population, persons with serious mental illness tend to have significantly
more medical comorbidities and higher mortality rates (1,2). Whether this
population also shows higher overall
cancer prevalence and mortality remains an epidemiological debate (3).
However, use of and access to preventive and general medical care
among persons with serious mental
illness is a major concern for consumers, providers, and policy makers.
The U.S. Preventive Services Task
Force, American Cancer Society, and
other medical organizations have
guidelines on screening for breast,
cervical, colorectal, and prostate cancers (4). Cancer screening and public
policies to promote such programs
have resulted in decreased cancer
mortality in the general population,
especially for breast and cervical cancers (5,6). However, very little information is available about use of cancer-screening services by persons
with mental illness. A few studies
have suggested that women with serious mental illness have lower use of
preventive breast and cervical cancer
screening than do women without serious mental illness (7,8). There is
very little information in the literature about the use of prostate and colorectal cancer screening in this population. This study examined utilization patterns of cancer-screening
services among consumers enrolled
in public-sector mental health clinics
in Sacramento County. Such information may be used to monitor health
♦ ps.psychiatryonline.org ♦ August 2008 Vol. 59 No. 8
care utilization by persons with serious mental illness and to guide public
policy (9).
Methods
The Sacramento County Health and
Human Services (SCHHS) Division
of Mental Health Services contracts
its outpatient mental health services
with four independent mental health
clinics. This study was approved by
the institutional review board at the
University of California, Davis, and
the SCHHS Research Committee.
Administrators from all four mental
health clinics agreed to participate in
the study, and they also provided office space for the interviews to take
place. Participants were approached
before their visits with their
providers or before group activities.
Interviewing took place before or after the visits. Participants were informed that they would be asked a
series of questions about their use of
preventive health services. Participation was voluntary, without any compensation and independent of routine care. Adult patients (age 18 and
up) with mental illness were sequentially approached and surveyed. The
interviews lasted ten to 20 minutes.
Participants were interviewed about
demographic characteristics, health
status, and use of preventive health
services. The most recent multiaxial
diagnostic information, based on the
DSM-IV-TR, was extracted from written charts.
A total of 387 participants were approached from January 20, 2005, to
929
Table 1
Self-reported use of cancer-screening services by 229 persons with serious
mental illness
Time of screen
N
Mammogram (N=111)a
Never
<1 year
≥1 but ≤2 years
>2 but ≤5 years
>5 years
Unsure or no response
Clinical breast exam (N=111)a
Never
<1 year
≥1 but ≤2 years
>2 but ≤5 years
>5 years
Unsure or no response
Pap test (N=121)
Never
≤3 years
>3 years
Unsure or no response
Prostate specific antigen test (N=62)b
Never
≤1 year
>1 year
Digital rectal exam (N=64)b
Never
≤1 year
≥1 but ≤2 years
>2 but ≤5 years
>5 years
Unsure or no response
Fecal occult blood test (N=68)c
Never
<1 year
≥1 but ≤2 years
>2 but ≤5 years
>5 years
Unsure or no response
Flexible sigmoidoscopy or colonoscopy (N=68)c
Never
≤5 years
>5 years
Unsure or no response
Any colorectal cancer screen (N=68)c
Never
Fecal occult blood test ≤1 year, flexible
sigmoidoscopy or colonoscopy ≤5 years,
or both
Fecal occult blood test >1 year, flexible sigmoidoscopy or colonoscopy >5 years, or both
Unsure or no response
a
b
c
%
95% CI
30
33
16
18
13
1
27
30
14
16
12
1
11%–43%
14%–45%
0%–32%
0%–33%
0%–29%
0%–19%
3
47
19
16
22
4
3
42
17
14
20
4
0%–21%
29%–58%
1%–35%
0%–32%
4%–37%
0%–22%
2
83
34
2
2
69
28
2
0%–19%
59%–79%
13%–43%
0%–19%
46
8
8
74
13
13
62%–87%
0%–36%
0%–36%
27
7
5
7
16
2
42
11
8
11
25
3
24%–61%
0%–48%
0%–43%
0%–48%
19%–68%
0%–37%
47
3
3
5
7
3
69
4
4
7
10
4
56%–82%
0%–54%
0%–54%
0%–61%
0%–68%
0%–54%
52
9
2
5
76
13
3
7
65%–88%
24%–89%
0%–58%
0%–72%
38
56
40%–72%
8
12
0%–34%
17
5
25
7
4%–46%
0%–30%
After age 29
After age 39
After age 49
May 30, 2007. From this sample, 153
participants declined to participate
and five participants provided incomplete data that were not analyzable,
yielding a total of 229 completed surveys for final analysis. For each question, answers were considered valid if
930
participants answered “unsure” or
“unknown,” and answers were not
scored if the question was left blank.
Study variables included age, gender,
ethnicity (white, African American,
Asian, Hispanic or Latino, American
Indian or Alaska Native, mixed ancesPSYCHIATRIC SERVICES
try, and other), marital status, education level (<12 years, high school or
GED, some college, and college
graduate), income (grouped into
<$10,000, $10,000–$15,000, and
>$15,000). All questions had an additional response of “don’t know/unsure” to provide participants the option to not answer questions.
Women were asked about their use
of mammogram services, clinical
breast exam, and the Papanicolaou
(Pap) test. Men older than 39 were
asked about their use of the prostatespecific antigen (PSA) test and digital
rectal exam for prostate cancer. All
participants older than 49 were asked
about colorectal cancer screening via
fecal occult blood stool test (FOBT)
and flexible sigmoidoscopy (flexsig)
or colonoscopy. For each cancerscreening service, participants were
asked about lifetime history of
screening (responses were yes, no,
and unsure). If an affirmative answer
was given, an additional question was
asked about whether the screening
had occurred in time intervals of less
than one year, between one and two
years, between two and three years,
between three and five years, more
than five years, or unsure or declined
to answer. For data analysis, descriptive statistics were reported as mean
and standard deviation for age and
percentages with 95% confidence intervals calculated for each categorical
variable. Data for year intervals were
combined when relevant to facilitate
presentation of the results.
Results
The participants’ mean±SD age was
40.15±10.10 years. There were 106
men (46%) and 123 women (54%).
Only 23 participants (10%) were married, and 184 participants (80%) were
enrolled in a government-sponsored
health care insurance program. Of
the 229 respondents, 55 (24%) did
not complete high school, 78 (34%)
completed high school or earned a
GED, and 95 (42%) had education
beyond high school. Primary diagnoses included 79 persons with schizophrenia (35%), 92 with bipolar disorder (40%), and 50 with recurrent
major depressive disorder (22%).
The use of cancer-screening services is summarized in Table 1. Most
♦ ps.psychiatryonline.org ♦ August 2008 Vol. 59 No. 8
women had received clinical breast
examination and cervical cancer
screening at least once in their lifetime. Among men older than 50 years
(data not shown in table), 21 of 32
(66%) had never received PSA testing
for prostate cancer. However, only
eight of 32 (25%) participants older
than age 50 had never received a digital rectal exam. Among eligible men
and women (over age 50), 38 out of 68
(56%) had never received screening
for colorectal cancer. The pattern for
up-to-date cancer screening (Table 1)
was similar, with more women having
had a Pap test in the past three years
(83 of 121, or 69%) than had a mammogram in the past year (30 of 111, or
30%), or for men a PSA test in the past
year (eight of 62, or 13%), or for all
participants an FOBT in the past year
or a flexsig or colonoscopy in the past
five years (eight of 68, or 12%).
Discussion
This study examined the utilization
patterns of cancer-screening services
among persons with serious mental
illness who were attending public
mental health clinics. This survey
found that the proportion of people
who had never had breast, colorectal,
or prostate cancer screening was
much higher compared with cervical
cancer screening. This finding may be
secondary to easier access to and earlier temporal indication of routine
screening for cervical cancer compared with the other cancers. For example, the Pap test is more readily
available via community programs
(such as Planned Parenthood), and
cervical cancer screening is offered
much earlier (within three years of
onset of sexual activity or at age 21).
Persons with serious mental illness
consistently received little up-to-date
screening of the four cancers considered in this study. This finding indicates that even among those who
have received cancer screening in the
past, persons with serious mental illness did not get cancer screening on a
routine basis. Recent colorectal cancer screening occurred least often.
The mechanisms behind these differences require further research,
and up-to-date cancer screening may
be a potential target for intervention.
Reasons for not getting routine
PSYCHIATRIC SERVICES
screening services among those who
received cancer screening in the past
are likely to be different compared
with those who have never received
any cancer-screening services in their
lifetime. This is an important area
that would require further research
from different vantage points—
among consumers, providers, and
health care administrators.
The use of preventive health services by persons with serious mental illness has been studied scantily in different settings, although methodologies have varied. Very few studies
have been based on interviews of persons with serious mental illness in
ambulatory settings. Most studies
have relied on chart review, physician
surveys, or insurance claims (10–12).
Of 43 participants ages 40–70 years,
Dickerson and colleagues (13) found
that eight (19%) had never received a
mammogram and 26 (61%) had received a mammogram in the past two
years (13). We report slightly lower
receipt of mammogram services, although our age cutoff was lower. Of
81 respondents who had received a
mammogram in their lifetime, only
49 of 111 women asked (44%) had received one in the past two years. In
another outpatient sample, Carney
and colleagues (14) found that 119
(90%) of 133 participants received at
least one Pap test. We found a similarly high rate of lifetime cervical cancer screening of 97%. Therefore, despite temporal and methodological
differences, our findings are largely
consistent with previous studies of
breast and cervical cancer screenings.
This study is the largest available
study based on personal surveys of
the use of cancer-screening services
in community mental health programs that we are aware of. We also
collected comparison data on use of
four cancer-screening services by persons with serious mental illness.
There are several methodological
limitations. First, we did not have information about participants who declined to participate in the survey. It
is possible that their use of preventive
health services is even lower. Second,
because we relied on patient recall
about receipt of the services, recall
bias may have decreased the accuracy
about actual receipt of services. This
♦ ps.psychiatryonline.org ♦ August 2008 Vol. 59 No. 8
limitation could be addressed by randomly validating the responses with
the participants’ medical records in
future studies. Third, we did not
characterize the settings where the
preventive services were provided
(for example, by mental health
providers or primary care providers).
Finally, we did not directly compare
persons with serious mental illness
with persons without serious mental
illness; rather, the survey clinical sample provided descriptive information
about persons enrolled in public mental health clinics.
Utilization of cancer-screening
services depends on many factors, including health attitude, perceived
discrimination, general disability,
number and severity of medical comorbidities, access to medical services, and recommendations from physicians (15). The results from this study
are not necessarily generalizable to
other mental health systems. However, our study highlights the importance and feasibility of personal
health surveys in monitoring the receipt of cancer-screening services by
enrollees of the public mental health
system.
Conclusions
This study examined the use of preventive cancer-screening services by
persons with serious mental illness.
The continued monitoring of the use
of cancer-screening services can be
informative as part of a general health
system performance measure and can
guide future resource allocation of
health promotion programs.
Acknowledgments and disclosures
This study was supported in part by a National
Alliance for Research on Schizophrenia and
Depression young investigator award to Dr.
Bermudes.
Dr. Bermudes was a speaker for Bristol-Myers
Squibb in 2007. The other authors report no
competing interests.
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