Evaluating the High SDOH Burden for Patients With Serious Mental Illness

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Two posters presented at AMCP Nexus 2021 review the high burden of social determinants of health (SDOH) on patients with serious mental illness.

Social determinants of health (SDOH) affect not only health but also outcomes such as medication adherence. In 2 posters presented at the Academy of Managed Care Pharmacy (AMCP) Nexus 2021 meeting, researchers reviewed the impact of SDOH on patients with severe mental illness (SMI).

In the first poster,1 which received a platinum poster award from AMCP, the researchers reviewed individuals with schizophrenia (SCA), bipolar type 1 disorder (BPD), and major depressive disorder (MDD), who were enrolled in commercial and managed Medicaid (MM) health plans from 2016 to 2018 using the Inovalon MORE2 Registry.

The analysis reviewed 1,038,075 patients in commercial plans and 1,234,371 in MM: 55,848 had SCZ, 212,349 had BPD, and 1,762,937 had MDD. Although the mean ages of the BPD and MDD cohorts were similar across commercial and MM plans, patients in a commercial plan who had SCZ were younger compared with the MM cohort (mean age, 40.6 vs 45.4 years, respectively).

The BPD and MDD cohorts were predominantly female, but the SCZ population was predominantly male. Across all the cohorts, patients had low Charlson Comorbidity Index scores, and the most common chronic condition was hypertension. The MM patients across all SMI were 3 to 4.5 times more likely to have low income.

“Results show patients with SMI have significant social risk factors that may negatively impact overall health outcomes, especially in patients with SCZ insured by Medicaid,” the authors concluded. They noted additional research will need to “explore the specific SDOH and patient characteristics associated with disparities in clinical and economic outcomes for each SMI.”

In the second poster,2 the same authors looked specifically at Medicare beneficiaries with the same 3 SMIs. They reviewed Medicare fee-for-service (FFS) and Medicare Advantage (MA) using claims data from 100% Medicare FFS and Inovalon’s MORE2 Registry, again.

There were a total of 2,649,135 beneficiaries reviewed with more in FFS (n = 2,342,270) than MA (306,865). The vast majority of patients had MDD (89%), followed by BPD (7.6%) and SCZ (3.6%). The mean age for each condition was similar between MA and FFS. Similar to the commercial and MM plans in the other poster, SCZ patients were more likely to be male, whereas MDD and BPD patients were more likely to be female.

The researchers also found that SCZ patients were more likely to be a minority compared with BPD and MDD:

  • 25.9% of patients with SCZ were Black in FFS and 34.0% in MA; 4.4% were Hispanic in FFS and 10.2% in MA.
  • 13.2% of patients with BPD were Black in FFS and 19.0% in MA; 3.1% were Hispanic in FFS and 8.0% in MA.
  • 8.2% of patients with MDD were Black in FFS and 13.3% in MA; 2.4% were Hispanic in FFA and 9.3% in MA.

In addition, whereas patients with MDD were primarily eligible for Medicare because of their age, patients with SCZ and BPD were mostly qualified because of disability. Beneficiaries with SCZ were also more likely to be dually eligible for Medicaid, with as many as 83% eligible for both compared with as much as 70% of patients with BPD and only 42% of patients with MDD.

Overall, the SDOH burden among Medicare beneficiaries with SMI is high, but it is especially so for patients with SCZ. Patients with SCZ were also less likely to be married or to own their own home. They were more likely to live alone, be below the federal poverty level, live in a high unemployment area, have high school education or less, not own a vehicle, and speak English not well or not at all.

“It is essential to understand the impact of SDOH on healthcare utilization and outcomes in the vulnerable Medicare population, which can compound their heavy comorbidity burden,” the authors wrote. “If unaddressed, social risk factors can lead to worse health outcomes and higher costs in the Medicare population with SMI.”


1. Mohammadi I, Teigland C, Agatep B, Hadzi Boskovic D, Kim S. High prevalence of social determinants of health compounds burden of illness in patients with severe mental illness. Presented at: AMCP Nexus 2021; October 18-21, 2021; Denver, CO. Abstract F19.

2. Teigland C, Mohammadi I, Agatep B, Hadzi Boskovic D, Kim S. Medicare beneficiaries with serious mental illness (SMI) have high prevalence of social determinants of health (SDOH). Presented at: AMCP Nexus 2021; October 18-21, 2021; Denver, CO. Abstract F20.