Depression, anxiety related to lower breast cancer screening rate

Researchers examine how psychological distress like depression and anxiety can affect preventive care in older adults
July 20, 2018

For adults over 65, staying healthy means following recommendations on several preventive care services, ranging from blood pressure and cholesterol checks to cancer screenings and a yearly flu shot. Research has shown that psychological distress such as depression and anxiety can hinder preventive care, with distressed patients being less likely to receive care. However, these studies and the data they use are several years old, and with recent advances in health care policy and a growing number of baby boomers joining the nearly 42 million people already in the older adult population, more updated information is needed.

Texas A&M School of Public Health researchers Szu-Hsuan Lin, PhD, Bita Kash, PhD, and Darcy McMaughan, PhD, along with colleagues from Texas State University and the U.S. Census Bureau, studied more recent health data to address this need. In their study, published in the Journal of Applied Gerontology, the researchers analyzed a dataset from the Medical Expenditure Panel Survey of 2011, which collected data on health care services use, cost of services and various demographic characteristics of a nationally representative sample of Americans. By selecting adults over 65 and using an established health care utilization model, Lin and colleagues were able to statistically analyze the data to see how psychological distress and other factors affect preventive care use.

The items of interest for this study were the use of five preventive care services within recommended time periods. These services were screening for breast and colorectal cancers, blood pressure and cholesterol checks and influenza vaccinations. The U.S. Preventative Services Task Force recommends the two cancer screenings and flu vaccine for older adults, and the blood pressure and cholesterol tests are frequently performed because high cholesterol and blood pressure are common in the older adult population, along with their known associated health risks.

To gain a clearer picture of how psychological distress affects use of these services preventively, not after a problem has already been recognized, the researchers excluded data on cancer screenings for subjects with a history of cancer and data on blood pressure and cholesterol tests for adults with a history of elevated cholesterol or high blood pressure. However, subjects excluded from a category were still included in the remaining groups.

To understand how use of these services can be affected, Lin and colleagues used Medical Expenditure Panel Survey data on mental health to measure levels of psychological distress, such as feelings of depression and anxiety. They also included data on other factors such as age, gender, race and ethnicity, marital status and education. Their analyses found no statistically significant difference in levels of psychological distress between men and women; however, older subjects and those who were racial or ethnic minorities, unmarried or had lower education attainment were more represented among the psychologically distressed. As for the use of preventive health services, the study found no significant differences between distressed and non-distressed groups for colorectal cancer screening, vaccination and blood pressure and cholesterol checks. However, they did find that patients with psychological distress were less likely to receive the recommended mammograms or other breast cancer screening.

These findings differ from the existing research, with previous studies finding that people with psychological distress less likely to undergo colorectal cancer screenings or get a yearly flu shot. The authors state this might be due to older adults now being more likely to have health insurance and a usual source of medical care, which other studies have found to be associated with proper preventive care. Additionally, health care systems have worked to improve quality of care and emphasize preventive care practices in recent years, but whether this can be attributed to change stemming from the Affordable Care Act remains to be seen.

However, disparities in breast cancer screening rates between distressed and non-distressed patients seem to exist even after health care reform made them inexpensive or even free for patients. Therefore, interventions may be necessary.

“Improved treatment of psychological distress could increase the rates at which distressed patients receive recommended breast cancer screenings,” Lin said.  “Other improvements that should be considered are higher levels of collaboration among primary care providers and specialists, increased use of electronic health information technology, especially automated reminder systems, and effective and culturally appropriate outreach and health promotion efforts.”

Additional research will help further clarify the role psychological distress plays in health care in older adults. Studies that examine differences between simple procedures like flu vaccination and more complex and multi-step services like cancer screenings will help shed light on this subject, as will research that considers alcohol use, family cancer history and other factors not included in this study. In addition, as the health care landscape continues to change, it will be crucial to collect updated data and look into the long-term effects that the Affordable Care Act and other reforms have on preventive care use.

“As the population of older adults continues to grow, the importance of preventive care services will take center stage,” Lin said. “By better understanding factors like psychological distress that affect preventive care use, the health care community can find ways to improve care and help older adults lead healthy lives.”

— Rae Lynn Mitchell

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