Unemployment, homelessness, and other societal outcomes in patients with schizophrenia: a real-world retrospective cohort study of the United States Veterans Health Administration database

Abstract

Background The burden associated with schizophrenia is substantial. Impacts on the individual, healthcare system, and society may be particularly striking within the veteran population due to the presence of physical and mental health comorbidities. Disease burden is also influenced by a complex interplay between social determinants of health and health disparities. The objective of the current study was to compare non-healthcare societal outcomes between veterans with and without schizophrenia in the United States Veterans Health Administration (VHA). Methods A retrospective cohort study was conducted using the VHA database (01/2013–09/2019; study period). Veterans with schizophrenia (≥2 diagnoses of ICD-9295.xx, ICD-10 F20.x, F21, and/or F25.x during the study period) were identified; the index date was the earliest observed schizophrenia diagnosis. Veterans with schizophrenia were propensity score-matched to those without schizophrenia using baseline characteristics. A 12-month baseline and variable follow-up period were applied. The frequency of unemployment, divorce, incarceration, premature death, and homelessness were compared between the matched cohorts using standardized mean difference (SMD). Risk of unemployment and homelessness were estimated using logistic regression models. Results A total of 102,207 veterans remained in each cohort after matching (91% male; 61% White [per AMA]; median age, 59 years). Among veterans with schizophrenia, 42% had a substance use disorder and 30% had mental health-related comorbidities, compared with 25 and 15%, respectively, of veterans without schizophrenia. Veterans with schizophrenia were more likely to experience unemployment (69% vs. 41%; SMD: 0.81), divorce (35% vs. 28%; SMD: 0.67), homelessness (28% vs. 7%; SMD: 0.57), incarceration (0.4% vs. 0.1%; SMD: 0.47), and premature death (14% vs. 12%; SMD < 0.1) than veterans without schizophrenia. After further adjustments, the risk of unemployment and of homelessness were 5.4 and 4.5 times higher among veterans with versus without schizophrenia. Other predictors of unemployment included Black [per AMA] race and history of substance use disorder; for homelessness, younger age (18–34 years) and history of mental health-related comorbidities were additional predictors. Conclusion A greater likelihood of adverse societal outcomes was observed among veterans with versus without schizophrenia. Given their elevated risk for unemployment and homelessness, veterans with schizophrenia should be a focus of targeted, multifactorial interventions to reduce disease burden.

Physical, Psychiatric, and Social Comorbidities of Individuals with Schizophrenia Living in the Community in Japan

“…A higher percentage of participants with schizophrenia were unemployed or had nonregular employment, had lower household incomes, were less likely to be married, and lived with their parents than participants without schizophrenia. Despite evidence indicating that individuals diagnosed with schizophrenia are more likely to be unemployed [22] or have lower income [73] than the general population, there is a paucity of research investigating whether they are more likely to be unmarried or residing with their parents. However, our finding is consistent with a previous Japanese study, which also found a high prevalence of unmarried, unemployed, and low household income among individuals with schizophrenia [15].…”

“…Depression in individuals with schizophrenia can exacerbate the symptoms of schizophrenia, worsen the quality of life, and increase the risk of suicide [20]. Unemployment in individuals with schizophrenia can reduce the quality of life and place an extended burden on social support and disability services [21][22][23]. Addressing physical, psychiatric, and social comorbidities in primary care in the community is crucial in improving the health outcomes of individuals with schizophrenia.…”

Psychiatric co‐morbidity in patients with hidradenitis suppurativa: A cross‐sectional study of clinical characteristics and burden of disease

“…Several studies on the effect of unemployment on physical and mental wellbeing have shown an increased risk of psychiatric disorders in unemployed persons, [33][34][35] suggesting a possible causal explanation for the increased risk of unemployment in the PCM group. As unemployment to some extent increases both the chances of illness and mortality, [36][37][38][39] this could pose an additional risk for the group of patients with both PCM and HS. Furthermore, unemployment serves as an additional factor in impairment of quality of life in patients with HS.…”

Establishing a Care Continuum for Cardiometabolic Conditions for Patients with Serious Mental Illness

“…Patients with SMI are likely to experience disadvantages of low socioeconomic status, low educational attainment, unemployment, social isolation, homelessness, criminal justice involvement, and substance use disorder, all of which are associated with an increased risk of developing cardiometabolic conditions [23][24][25][26]. They may also be more likely to live in congregate settings, with limited control of menu planning and choice of healthy foods.…”