1. Introduction Introduction is present and distinctly establishes the purpose of paper. • Introduction is appealing and promptly captures the attention of the reader. (10 points) 2. article summary Statistics presented strongly support the significanc

20181010040018contentserver.asp_3_copy
 

1. Introduction

Introduction is present and distinctly establishes the purpose of paper. • Introduction is appealing and promptly captures the attention of the reader. (10 points)

2. article summary

Statistics presented strongly support the significance of the topic. • Key points and findings of the article are clearly stated. • Thoroughly discusses how information from the article could be used in your practice by giving two or more specific, relevant examples. (30 points)

3. article critique

The strengths and weaknesses are well‐defined and clearly stated. • Provides a thorough review of whether or not they recommend the article. (30 points)

4. conclusion

The conclusion statement is well‐defined and clearly stated. • Conclusion demonstrates comprehensive analysis or synthesis of information from the article. • The conclusion is strongly supported by ideas presented throughout the body of the paper. (20)

5. Grammar/spelling/Mechanics/APA format

References are submitted with assignment. • Used appropriate APA format and are free of errors. • Includes title and reference pages. • Grammar and mechanics are free of errors. (10 points)

NOTE: 

Townsend, M. C. and Morgan, K. I. (2018). Psychiatric mental health nursing: Concepts of care in evidence-based practice (9th ed.). F.A. Davis.

(this is textbook), one from here and one reference should be from article i attached. thanks!

Hospital Care for Mental Health and Substance Abuse Conditions in
Parkinson’s Disease

Allison. W. Willis, MD, MSCI,1,2,3,4* Dylan P. Thibault, MS,1 Peter N. Schmidt, PhD,5 E. Ray Dorsey, MD, MBA,6 and
Daniel Weintraub, MD1,7,8

1Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia,

Pennsylvania, USA

2
Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

3
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA

4
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA

5
National Parkinson’s Foundation, Miami, Florida, USA

6Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
7
Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

8
Parkinson’s Disease and Mental Illness Research, Education and Clinical Centers, Philadelphia Veterans Affairs Medical Center, Philadelphia,

Pennsylvania, USA

A B S T R A C T : O b j e c t i v e : The objective of this
study was to examine mental health conditions among
hospitalized individuals with Parkinson’s disease in the
United States.
M e t h o d s : This was a serial cross-sectional study of
hospitalizations of individuals aged �60 identified in the
Nationwide Inpatient Sample dataset from 2000 to
2010. We identified all hospitalizations with a diagnosis
of PD, alcohol abuse, anxiety, bipolar disorder, depres-
sion, impulse control disorders, mania, psychosis, sub-
stance abuse, and attempted suicide/suicidal ideation.
National estimates of each mental health condition
were compared between hospitalized individuals with
and without PD. Hierarchical logistic regression models
determined which inpatient mental health diagnoses
were associated with PD, adjusting for demographic,
payer, geographic, and hospital characteristics.
R e s u l t s : We identified 3,918,703 mental health and sub-
stance abuse hospitalizations. Of these, 2.8% (n 5 104,
437) involved a person also diagnosed with PD. The major-
ity of mental health and substance abuse patients were
white (86.9% of PD vs 83.3% of non-PD). Women were

more common than men in both groups (male:female
prevalence ratio, PD: 0.78, 0.78-0.79, non-PD: 0.58, 0.57-
0.58). Depression (adjusted odds ratio 1.32, 1.31-1.34),
psychosis (adjusted odds ratio 1.25, 1.15-1.33), bipolar
disorder (adjusted odds ratio 2.74, 2.69-2.79), impulse
control disorders (adjusted odds ratio 1.51, 1.31-1.75),
and mania (adjusted odds ratio 1.43, 1.18-1.74) were more
likely among PD patients, alcohol abuse was less likely
(adjusted odds ratio 0.26, 0.25-0.27). We found no PD-
associated difference in suicide-related care.
C o n c l u s i o n s : PD patients have unique patterns of
acute care for mental health and substance abuse.
Research is needed to guide PD treatment in individuals
with pre-existing psychiatric illnesses, determine cross
provider reliability of psychiatric diagnoses in PD
patients, and inform efforts to improve psychiatric out-
comes. VC 2016 International Parkinson and Movement
Disorder Society.

K e y W o r d s : Parkinson’s disease; suicide; psychia-
try; addiction; epidemiology

Parkinson’s disease (PD) is a common neurodegener-
ative disease that is diagnosed in 2% of older adults
in the United States.1 PD is associated with psychiatric
disorders such as depression, anxiety, and psychosis,
which can occur as part of the disease processes or as
a treatment side effect.2,3 In addition, PD patients may
be at higher risk for impulse-control disorders (ICDs;
compulsive gambling, buying, sexual and eating
behaviors) and dopamine dysregulation syndrome
(compulsive PD medication use),4 and these disorders

————————————————————
*Corresponding author: Dr. Allison Willis, Blockley Hall, 723, 423
Guardian Drive, Philadelphia, PA 19104; allison.willis@uphs.upenn.edu

Funding agencies: This study was funded primarily by the National Insti-
tutes of Health (NIH) and the National Institute of Neurological Disease and
Stroke (NINDS) via a Mentored Career Development Award
K23NS081087(PI-Willis) and the University of Pennsylvania Perelman School
of Medicine Department of Neurology Movement Disorders Division.

Relevant conflicts of interests/financial disclosures: Nothing to report.
Received: 4 February 2016; Revised: 19 July 2016; Accepted: 24
August 2016

Published online in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/mds.26832

R E S E A R C H A R T I C L E

1810 Movement Disorders, Vol. 31, No. 12, 2016

have been described as side effects of all classes of
dopaminergic medications used to treat the motor
symptoms of PD.5

Current epidemiology studies of psychiatric illness in
PD primarily contain data from neuropsychiatric
research instruments administered to academic center
or clinical trial populations. Most studies focus on the
prevalence of psychiatric conditions or symptoms and
draw conclusions based on populations of 10 to 200,
with the largest study to date examining 423 de novo
patients enrolled in a specialty center observational
study.6,7 This approach provides valuable granular
detail on psychiatric symptoms and illness in PD at
the expense of offering perspectives on psychiatric ill-
ness in female, Asian, Black, or Hispanic individuals
with PD, because these groups are underrepresented in
specialty center and clinical trial populations. Current
data on health care utilization associated with psychi-
atric illness have focused on the U.S. veteran popula-
tion. A national veteran’s affairs database study found
that veterans diagnosed with PD and depression were
more likely to have other medical diagnoses (such as
stroke, congestive heart failure, diabetes, chronic
obstructive pulmonary disease), were more likely to
have medical (odds ratio [OR] 5 1.34, 1.25-1.44) and
psychiatric hospitalizations (OR 5 2.14, 1.83-2.51),
and had more outpatient visits than PD patients with-
out a depression diagnosis.8 Two regional veteran’s
affairs studies also found increased outpatient health
care use and greater comorbid burden among veterans
with a recorded mental illness diagnosis.9,10

Although there are numerous studies of mood disor-
ders in PD, the data on suicide and PD consist largely
of individual case reports of suicidal attempts11-13 and
question whether dopaminergic intoxication/with-
drawal or deep brain stimulation (DBS) surgery14,15

are contributing factors. Two academic center-based
studies separately reported that suicidal ideation or
attempts in PD patients correlated with measures of
depression and anxiety.16,17 It is unclear whether the
increased depression and anxiety experienced by PD
patients translates into a greater burden of health care
utilization for suicide attempts/ideations.

Current PD care guidelines endorse outpatient
screening for symptoms and signs of depression, anxi-
ety, ICDs, and psychosis.18 Utilization data on acute
care for psychiatric emergencies in the PD population
would provide the necessary foundation for evalua-
tions of the effectiveness of such guidelines and may
generate hypotheses about the community level burden
of highly relevant but less-studied mental health condi-
tions (eg, substance abuse, suicide attempt).

The aim of this study was to investigate the patterns
of acute care for mental health and substance abuse
(MHSA) conditions among individuals diagnosed with
PD. We used data from the Nationwide Inpatient

Sample (NIS) Database, which contains detailed
patient, clinical, hospital, and payer data from hospi-
tal discharges from 44 states to characterize and com-
pare psychiatric hospitalizations of persons with and
without PD. Knowing the patterns of severe psychiat-
ric illness in PD would increase public and clinician
understanding of disabling aspects this disease as well
as provide new potential targets for preventive
strategies.

Methods

This study was approved by the institutional review
board at the University of Pennsylvania.

Study Dataset

The NIS is the largest all-payer inpatient care health
care utilization database in the United States and con-
tains data from approximately 8 million hospital stays
each year. The hospital universe that the NIS draws
from consists of community hospitals, as defined by
the American Hospital Association, excluding rehabili-
tation hospitals. The American Hospital Association
defines a community hospital as a “nonfederal short
term general and other specialty hospitals, excluding
hospital units of institutions.” Veteran hospitals and
other federal hospitals are excluded. Hospitals are
stratified by census region (Northeast, Midwest, West,
South) and location (rural, urban), and then progres-
sively by teaching status (teaching, nonteaching), bed
size category (small, medium, large), and ownership
(public, private not-for-profit, proprietary). A random
sample of 20% of hospitals in each stratum is drawn,
and all discharges from the sampled hospitals are
included in the NIS. Sample weights and statistical
programs that account for the stratification and survey
design are provided to allow researchers to calculate
national estimates and confidence intervals, such that
researchers can expect that the NIS data collection
process will not impact study results.

Study Population

The study population consisted of adults aged 60
and older who were hospitalized at a NIS community
hospital between January 1, 2000, and December 31,
2010. We chose to limit this study to older adults to
capture the population most at risk for PD and to
minimize the contributions of age-related variability in
psychiatric illness, such as the increased risk of schizo-
phrenia diagnosis in individuals aged 20 to 29 and dis-
tinct psychiatric comorbidity and health utilization
patterns in younger PD patients.19 We excluded indi-
viduals diagnosed with secondary or drug-induced
parkinsonism to limit the impact of coding error. Per-
sons with PD were identified using the International
Classification of Diseases, Ninth Revision, Clinical

A C U T E P S Y C H I A T R I C C A R E O F P A R K I N S O N D I S E A S E

Movement Disorders, Vol. 31, No. 12, 2016 1811

Modification (ICD-9-CM) codes 332 (PD) or 332.0
(paralysis agitans). Individuals without a PD diagnosis
were designated as controls. We extracted patient
characteristics (age, sex, race, age, primary insurance/
expected payer) and all recorded inpatient diagnoses.
Hospital characteristics available to us included hospi-
tal size (defined in the NIS using the number of inpa-
tient beds and categorized as small, medium, or large),
teaching status, and hospital location (rural/urban).

Our primary event of interest was hospital care for
MHSA conditions, identified using the Health Care
Utilization Project Mental Health Substance Abuse
Clinical Classification Software.20 We identified hospi-
talizations with a primary discharge diagnosis of alco-
hol abuse, anxiety, bipolar disorder, depression, ICDs,
mania, psychosis, psychotic depression, substance
abuse, and attempted suicide/suicidal ideation.

Statistical Analyses

The NIS is a 20% stratified probability sample of
hospital admissions; therefore, stratification clustering
and survey weights are required to calculate national
estimates of particular diagnoses. The weighted pro-
portions of each mental health/substance abuse condi-
tion were compared between inpatients with and
without PD. Demographic and hospital characteristic
variables were compared by PD diagnosis status using
a Pearson chi-square or Mann-Whitney U test. Logis-
tic regression models were built to compare the odds
of each MHSA diagnosis in PD versus the general
inpatient population and examine the associations of
individual characteristics (race, age, sex) with a
MHSA diagnosis. Our models adjusted for payer
(Medicare, Medicaid, private, health maintenance
organization, or self-pay), admission type (emergent,
elective), and hospital teaching status (teaching, non-
teaching). Several states in the NIS withhold race
data21; these states were excluded from race/sex
analyses.

We performed several sensitivity analyses, consider-
ing that coding accuracy and bias can affect claim-
based studies. We allowed a MSHA diagnosis in any
position (not only the primary diagnosis), performed
analyses stratified by hospital teaching status, payer
type. We also repeated our analyses in the subset of
NIS hospitals, which are also designated as primary
stroke centers, which are more likely to have subspeci-
alty care. All statistical analyses were performed using
SAS version 9.3 software (SAS Institute, Inc., Cary,
North Carolina).

Results

Demographic Characteristics

We identified 3,918,703 qualifying hospitalizations
for MHSA 2000-2010 NIS data. Of these, 2.8%

(n 5 104,437) involved a person also diagnosed with
PD. The majority of MHSA hospitalizations involved
white individuals (86.9% in the PD group vs 83.3%
in the control group). The PD group contained fewer
hospitalizations of black patients (prevalence
ratio 5 0.51, 0.50-0.53) and more hospitalizations of
Asian patients (prevalence ratio 5 1.32, 1.25-1.39;
Table 1). The age distribution of MHSA hospitaliza-
tions in the PD group was left skewed: 7%
(n 5 9,817) were individuals aged 60 to 64; this pro-
portion grew to 41% (n 5 55,014) for PD patients
aged 80 years and older. MHSA burden was more
evenly distributed across age strata in the general
inpatient group (Table 1). These findings agree with
previous studies that demonstrate (1) PD prevalence
increases with age and (2) psychosis and complicated
dementia are more common in older PD patients or in
later disease stages.2,18,22 Several studies have reported
that women are more likely to have a documented
psychiatric diagnosis or use psychiatric care serv-
ices.23-25 We found sex differences of MHSA diagno-
ses in both inpatient groups, but the magnitude of the
difference was less in the PD population (male:female
prevalence ratio PD 0.78, 0.78-0.79 vs general 0.58,
0.57-0.58).

MHSA Diagnoses Associated With PD
Affective Disorders

As shown in Table 2, affective disorders (anxiety,
depression, bipolar disorder, or mania) accounted for
88% of hospitalizations of persons with PD com-
pared to 78.8% of psychiatric hospitalizations in the
general population (chi square, P < .01). Multivari- able regression models that adjusted for patient, pay- er, and hospital factors found that hospitalized PD patients had greater odds of diagnosis of bipolar dis- order (adjusted odds ratio [AOR] 2.74, 2.69-2.79), mania (AOR 1.43, 1.18-1.74), and depression (AOR 1.32, 1.31-1.34). An admitting diagnosis of anxiety disorder was less likely among PD patients (AOR 0.68, 0.67-0.69).

Addiction

Only 4.2% of PD group hospitalizations were for
alcohol intoxication, abuse, or dependence compared
with 13.6% in the control group (P < .001). This dif- ference represented a 74% lower likelihood of an alcohol abuse diagnosis among PD inpatients (AOR 0.26, 0.25-0.27; Table 2, Fig. 1). Conversely, the odds of a substance abuse diagnosis were slightly more like- ly in the PD group (AOR 1.06, 1.04-1.09).

Suicide

Not all psychiatric behaviors or diagnoses were
more common in PD. Hospitalization for suicide

W I L L I S E T A L

1812 Movement Disorders, Vol. 31, No. 12, 2016

ideation or attempt was less common among PD
patients (0.84% vs 0.99% in the general population,
chi-square P < .05). However, the adjusted odds of a

suicide-related hospitalization were not statistically
different between PD patients and controls (AOR
0.98, 0.92-1.04).

TABLE 1. Population characteristics of older adult mental health and substance abuse hospitalizations, nationwide inpatient
sample, 2000-2010

Characteristics (no. of nonmissing data) PD (%) General population (%)

Prevalence ratio (95%CI)

PD vs. general population

Race (n 5 3,918,703)*
White 91, 809 (86.9) 3,175,455 (83.3) 1.04 (1.04-1.05)
Black 4095 (3.9) 289,341 (7.6) 0.51 (0.50-0.53)
Hispanic 5985 (5.7) 223,101 (5.8) 0.93 (0.90-0.95)
Asian 1397 (1.3) 38,201 (1.0) 1.32 (1.25-1.39)
Native American 304 (0.3) 14,418 (0.4) 0.76 (0.68-0.85)
Unknown 1947 (1.8) 72,650 (1.9) 0.97 (0.93-1.01)
Age group (n 5 4,998,604)
60-64 9817 (7.4) 960,977 (19.7) 0.37 (0.37-0.38)
65-69 15,511 (11.7) 881,175 (18.1) 0.65 (0.64-0.65)
70-74 21,986 (16.6) 787,493 (16.2) 1.02 (1.01-1.04)
75-79 30,410 (22.9) 799,649 (16.4) 1.39 (1.38-1.41)
801 55,014 (41.4) 1,436,572 (29.5) 1.40 (1.39-1.41)
Sex (n 5 4,998,604)
Male 58,399 (44.0) 1,787,796 (36.7) 1.20 (1.19-1.20)
Female 74,339 (56.0) 3,078,070 (63.3) 0.89 (0.88-0.89)
Expected primary payer (n 5 4,991,268)
Medicare 118,784 (89.6) 3,838,248 (79.0) 1.13 (1.13-1.14)
Medicaid 2804 (2.1) 205,773 (4.2) 0.50 (0.48-0.52)
Private insurance 9238 (7.0) 669,272 (13.8) 0.51 (0.50-0.52)
Self pay 558 (0.4) 63,791 (1.3) 0.32 (0.30-0.35)
No charge 70 (0.05) 7035 (0.1) 0.36 (0.29-0.46)
Other 1088 (0.8) 74,607 (1.5) 0.53 (0.50-0.57)
Admission type (n 5 4,484,731)
Emergent 73,576 (62.4) 2,618,335 (60.0) 0.03 (0.03-0.03)
Urgent 23,912 (20.3) 872,784 (20.0) 0.03 (0.03-0.03)
Elective 20,006 (17.0) 863,039 (19.8) 0.02 (0.02-0.02)
Trauma 161 (0.1) 8006 (0.20) 0.02 (0.02-0.02)
Other 169 (0.1) 4744 (0.10) 0.03 (0.03-0.04)
Hospital teaching status (n 5 4,976,467)
Nonteaching 83,159 (62.9) 2,932,836 (60.5) 1.17 (1.16-1.17)
Teaching 49,026 (37.1) 1,911,446 (39.5) 1.05 (1.05-1.06)

CI, confidence interval.

TABLE 2. Mental health and substance abuse hospitalization patterns in Parkinson’s disease versus the general population,
Nationwide Inpatient Sample, 2000-2010

Diagnosis

MHSA hospitalizations

PD vs. general population

adjusted ORb (95%CI)

PD General population

n %a n %a

Alcohol abuse 5601 4.2 682,966 14.0 0.26 (0.25-0.27)
Anxiety 24,349 18.3 1,232,109 25.3 0.68 (0.67-0.69)
Bipolar 14,708 11.1 261,327 5.4 2.74 (2.69-2.79)
Depression 77,697 58.5 2,469,428 50.8 1.33 (1.31-1.34)
Impulse control 227 0.2 4897 0.1 1.52 (1.31-1.76)
Mania 118 0.1 3285 0.1 1.44 (1.18-1.74)
Psychosis 996 0.8 29,512 0.6 1.25 (1.17-1.33)
Substance abuse 8191 6.2 301,892 6.2 1.06 (1.04-1.09)
Suicide 1121 0.8 49,906 1.0 0.98 (0.92-1.04)

CI, confidence interval; MHSA, mental health and substance abuse; OR, odds ratio.
aTotal percentage may be greater than 100 because multiple diagnoses are allowed per hospitalization.
bAdjusted for sex, age, payer, admission type, and teaching status.

A C U T E P S Y C H I A T R I C C A R E O F P A R K I N S O N D I S E A S E

Movement Disorders, Vol. 31, No. 12, 2016 1813

Impulse-Control Disorders

ICDs are associated with dopaminergic medication
use in PD,26 and psychosis in PD may be primary or
may occur secondary to PD medication use, infections,
metabolic derangements, or acute drug reactions. Hos-
pitalization for both ICDs and psychosis were more
common in the PD group (ICD: 0.17% in the PD
group vs 0.10% in the control group; psychosis:
0.75% in the PD group vs 0.59% in the control
group; P < .001 for both comparisons).

Demographic Differences in MHSA Diagnoses

Table 3 displays the results of subgroup analyses
that examined the extent to which inpatient diagnoses
varied by race and gender between PD and control
groups, adjusting for age, hospital, and payer charac-
teristics. In general, the associations between PD and
mood disorders, bipolar disorder, psychosis, impulse
disorders, and alcohol abuse were preserved across
race and sex subgroups. However, substance abuse
was more likely in white (AOR 1.13, 1.10-1.67) and
male (AOR 1.15, 1.11-1.20) PD patients, and less
likely in blacks with PD (AOR 0.69, 0.60-0.79). Hos-
pitalization with suicide ideation or attempt was
increased in the Hispanic PD group (AOR 1.42, 1.06-
1.90). The sensitivity analyses (as described in the
Methods section) did not produce adjusted odds ratios
that differed substantially in magnitude in direction
from our primary analyses (Supplementary Table 1).

Discussion

In this health care utilization study, we examined
MHSA hospitalizations of older adults with PD. Psy-
chiatric disorders are common in PD and are associat-
ed to varying degrees with disease processes (specific
neurotransmitters, brain regions, and neural circuits)
and PD treatments (dopaminergic medications and
DBS). Depression and anxiety may precede PD motor
signs by several years,27,28 lending biological plausibil-
ity for the high prevalence of these disorders in PD
patients.29,30 Psychosis, ICDs, and mania most com-
monly occur in the context of treatment with dopami-
nergic therapy or other PD treatments (eg, DBS,
amantadine, or anticholinergic medications), although
psychosis is also associated with the disease process
itself. Our data demonstrate that PD patients have dis-
tinct acute care needs for mental illnesses, potentially
providing new insights about the relationships
between PD and psychiatric disorders and informing
efforts to improve outcomes in PD.

Measuring the burden of psychiatric illness using
hospital discharge data provides a different perspective
than psychometric studies of academic center popula-
tions. Hospitalization for a given illness not only
reflects its baseline prevalence in a population but also
the effectiveness of outpatient screening, detection,
action, and the relative success of outpatient treat-
ment. The higher likelihood of a depression diagnosis
in PD patients is consistent with the high prevalence
(30%-40%) of depression in PD, but also indicates

FIG. 1. Mental health and substance abuse hospitalizations in PD versus general population. OR, odds ratio. [Color figure can be viewed at wileyon-
linelibrary.com]

W I L L I S E T A L

1814 Movement Disorders, Vol. 31, No. 12, 2016

http://wileyonlinelibrary.com

http://wileyonlinelibrary.com

TABLE 3. Mental health and substance abuse hospitalizations in Parkinson’s disease by race and sex, Nationwide Inpatient
Sample 2000-2010

Diagnosis
MHSA hospitalizations

PD vs. General Population,

Adjusted ORa (95%CI)

PD General population

No./total no. Prevalence, % No./total no. Prevalence, %

Alcohol abuse
White 3808/91,809 0.04 400,051/3,175,455 0.13 0.29 (0.28-0.30)
Black 379/4095 0.09 78,065/289,341 0.27 0.27 (0.24-0.31)
Hispanic 309/5985 0.05 40,113/223,101 0.18 0.21 (0.18-0.25)
Asian 32/1397 0.02 4257/38,201 0.11 0.11 (0.06-0.21)
Male 4490/58,399 0.08 511,377/1,787,796 0.29 0.27 (0.26-0.28)
Female 1111/74,339 0.01 171,589/3,078,070 0.06 0.31 (0.29-0.33)
Anxiety disorder
White 16,803/91,809 0.18 823,749/3,175,455 0.26 0.66 (0.65-0.67)
Black 557/4095 0.14 52,892/289,341 0.18 0.67 (0.61-0.74)
Hispanic 1199/5985 0.20 53,962/223,101 0.24 0.76 (0.70-0.82)
Asian 229/1397 0.16 9555/38,201 0.25 0.64 (0.51-0.81)
Male 8806/58,399 0.15 349,131/1,787,796 0.20 0.70 (0.68-0.71)
Female 15,543/74,339 0.21 882,978/3,078,070 0.29 0.65 (0.64-0.66)
Bipolar disorder
White 10,601/91,809 0.12 177,984/3,175,455 0.06 2.74 (2.68- 2.8)
Black 451/4095 0.11 14,786/289,341 0.05 2.91 (2.62- 3.23)
Hispanic 470/5985 0.08 9065/223,101 0.04 2.3 (2.05- 2.59)
Asian 111/1397 0.08 1553/38,201 0.04 3.07 (2.29-4.1)
Male 6499/58,399 0.11 88,203/1,787,796 0.05 2.9 (2.8-2.99)
Female 8209/74,339 0.11 173,124/3,078,070 0.06 2.57 (2.5-2.65)
Depression
White 53,935/91,809 0.59 1,657,607/3,175,455 0.52 1.28 (1.26-1.3)
Black 2291/4095 0.56 114,700/289,341 0.40 1.7 (1.59-1.82)
Hispanic 3326/5985 0.56 102,159/223,101 0.46 1.38 (1.3-1.47)
Asian 806/1397 0.58 18,476/38,201 0.48 1.66 (1.39-1.99)
Male 32844/58,399 0.56 746,793/1,787,796 0.42 1.48 (1.45-1.51)
Female 44853/74,339 0.60 1,722,635/3,078,070 0.56 1.15 (1.12-1.17)
Psychosis
White 698/91,809 0.21 18,993/3,175,455 0.00 1.27 (1.17-1.38)
Black 28/4095 0.04 177/289,341 0.00 1.11 (.76-1.63)
Hispanic 223/5985 0.22 1319/223,101 0.00 1.35 (0.99-1.85)
Asian 13/1397 0.16 229/38,201 0.00 1.63 (0.75-3.51)
Male 505/58,399 0.01 11,619/1,787,796 0.01 1.35 (1.21-1.50)
Female 491/74,339 0.01 17,893/3,078,070 0.01 1.18 (1.06-1.31)
Substance abuse
White 5687/91,809 0.06 179,247/3,175,455 0.06 1.13 (1.10-1.17)
Black 259/4095 0.06 35,611/289,341 0.12 0.69 (0.60-0.80)
Hispanic 275/5985 0.05 13,087/223,101 0.06 0.92 (0.79-1.08)
Asian 70/1397 0.05 1925/38,201 0.05 0.73 (0.47-1.14)
Male 4384/58,399 0.08 143,014/1,787,796 0.08 1.15 (1.11-1.20)
Female 3807/74,339 0.05 158,878/3,078,070 0.05 1.04 (1.00-1.09)
Suicide
White 793/91,809 0.01 33,467/3,175,455 0.01 0.95 (0.88-1.03)
Black 35/4095 0.01 288/289,341 <0.01 1.23 (0.87-1.73) Hispanic 61/5985 0.01 2129/223,101 0.01 1.42 (1.06-1.90) Asian 20/1397 0.01 662/38,201 0.02 0.77 (0.38-1.57) Male 621/58,399 0.01 23,298/1,787,796 0.01 0.97 (0.88-1.07) Female 500/74,339 0.01 26,608/3,078,070 0.01 0.94 (0.85-1.05) Mania White 82/91,809 0.02 2201/3,175,455 <0.01 1.42 (1.23-1.80) Black 0/4095 0.04 165/289,341 <0.01 <0.001 (<0.001->999.99)
Hispanic 7/5985 0.02 98/223,101 <0.01 2.50 (0.90-6.87) Asian 0/1397 0.03 35/38,201 <0.01 <0.001 (<0.001->999.99)
Male 65/58,399 0.00 1223/1,787,796 <0.01 1.66 (1.27-2.18) Female 53/74,339 0.00 2062/3,078,070 <0.01 1.25 (0.94-1.65) Impulse control White 161/91,809 <0.01 3146/3,175,455 <0.01 1.52 (1.27-1.82)

(Continued)

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Movement Disorders, Vol. 31, No. 12, 2016 1815

that severe depression (requiring hospitalization) is
also common in PD. In contrast, a higher risk of bipo-
lar disorder associated with PD has not been reported
previously. The direction of this finding was robust to
several sensitivity analyses, although the magnitude
was decreased among hospitals that likely have inpa-
tient neurological and psychiatric care available. A
greater need for inpatient care for bipolar disorder
may reflect the difficulty treating emergent PD in an
older adult with a history of bipolar disorder. Basic
PD symptom management can precipitate a manic epi-
sode in a person with previously controlled bipolar
disorder both directly (by the use of dopaminergic
medications) or indirectly (by attempting to discontin-
ue lithium or neuroleptics). Inexperienced clinicians
may misdiagnose PD patients presenting with mania,
ICD behaviors, sleep disturbance, hyperkinesis/dyski-
nesias, akathisia, or tachyphemia (as a result of the
disease process of PD drugs) and a history of depres-
sion as having bipolar disorder.

Anxiety disorders are very common in PD, so it
might be considered surprising that PD patients were
less likely to have an anxiety disorder listed as an
admission diagnosis. Depression and anxiety disorders
are highly comorbid in PD (up to 80%), but research
emphasizes detecting and treating depression and
ICDs. Patients with anxiety and depression symptoms
may have been coded as having a primary depression
diagnosis on admission. Alternatively, anxiety symp-
toms occurring in PD may require psychiatric hospital-
ization less often.

The prevalence of attempted or completed suicide in
PD is not known, although death ideation is com-
mon.17 Previous research has not reported higher rates
of suicide in PD when compared with the general pop-
ulation, even post-DBS surgery.31-33 Our results of rel-
atively high burden admission for depression but no
increased risk of suicide ideation or behaviors likely
reflects practice patterns: PD patients are admitted for
depression in the absence of suicidality versus patients

in the general population, where suicidality is more
likely to prompt admission.

The association between substance use and alcohol
disorders and PD appears complex. PD patients are
not widely thought to be at increased risk of substance
use disorders; rather, it has been hypothesized that PD
patients are risk aversive as a result of disease-related
personality changes.34 Substance abuse disorders can
be a manifestation of ICDs in PD.35,36 A Swedish reg-
istry study that found a history of admission for alco-
hol abuse was associated with increased risk (HR 1.38,
1.25-1.53) of a future diagnosis of PD, an intriguing
finding potentially linking the biological processes of
the 2 diseases.37 The relationship was strongest for the
younger onset population, and our previous studies of
disabled younger PD patients also found an increased
risk of hospitalization for substance abuse,19 together
suggesting an interaction between age and substance
use disorders in PD patients.

Our subpopulation analyses found that race, and to
a lesser extent sex, were moderators of psychiatric
admissions when comparing PD patients with the gen-
eral population. White PD patients were more likely
to be hospitalized for substance abuse, whereas His-
panics were more vulnerable to hospitalization for sui-
cidal ideation or attempt. These differences may
reflect cultural differences in the tendency to seek hos-
pital care for mental illness, reduced access of hospi-
talization, or be evidence of a greater requirement for
inpatient treatment. Another possibility is that our
subpopulation data reflects the underservice of PD
patients who are black or Asian, groups who experi-
ence greater disparities in specialty care38,39 and state-
of-the-art care40 compared with whites and Hispanics.
Of course, there may be genetic differences in pheno-
type, which remain understudied despite the known
race and gender-associated differences in risk for
developing PD.22,41,42 Future studies are needed to
investigate further race disparities in suicide and sub-
stance abuse in PD.

TABLE 3. Continued

Diagnosis
MHSA hospitalizations
PD vs. General Population,
Adjusted ORa (95%CI)
PD General population
No./total no. Prevalence, % No./total no. Prevalence, %

Black 12/4095 <0.01 287/289,341 <0.01 2.56 (1.35-4.85) Hispanic 7/5985 <0.01 164/223,101 <0.01 1.49 (0.60-3.66) Asian 2/1397 <0.01 57/38,201 <0.01 <0.001 (<0.001-999.99) Male 171/58,399 <0.01 3111/1,787,796 <0.01 1.64 (1.35-1.98) Female 56/74,339 <0.01 1786/3,078,070 <0.01 1.29 (0.91-1.82)

CI, confidence interval; MHSA, mental health and substance abuse; OR, odds ratio.
aAdjusted for age, sex, payer, hospital type, and admission type.
Additional Supporting Information may be found in the online version of this article at the publisher’s website.

W I L L I S E T A L

1816 Movement Disorders, Vol. 31, No. 12, 2016

This represents the largest study of psychiatric ill-
ness in PD, and the results indicate differences in pat-
terns of acute psychiatric hospitalizations in PD
patients when compared with the general population.

These differences possibly reflect the increased risk in
PD patients for certain psychiatric disorders, the asso-
ciation between PD medications and certain psychiat-
ric side effects, possible disparities in quality

TABLE 1. MHSA Hospitalizations in Parkinson Disease according to Hospital Teaching Status, Primary stroke center, and
Payer type, NIS 2000-2010

Diagnosis

MHSA Hospitalizations

PD vs. General Population

Adjusted OR** (95%CI)

PD General Population

No. / Total No. Prevalence % No. / Total No. Prevalence %

Alcohol Abuse
Overall 5601 4.2% 682,966 14.0% 0.26 (0.25- 0.27)
Teaching hospitals ** 1,126 / 54,800 2.06 220,848 / 1,631,714 13.53 0.14 (0.12-0.17)
Primary Stroke Centers *** 443 / 17,870 2.48 92,329 / 649,636 14.21 0.16 (0.12-0.21)
Medicare**** 1,976 / 123,302 1.60 298,142 / 3,144,156 9.48 0.14 (0.12-0.16)
Medicaid**** 251 / 4,677 5.37 51,258 / 248,126 20.66 0.26 (0.18-0.37)
Private**** 314 / 10,665 2.94 105,079 / 480,799 21.86 0.12 (0.09-0.16)
Anxiety Disorder
Overall 24,349 18.3% 1,232,109 25.3% 0.68 (0.67- 0.69)
Teaching hospitals 818 / 54,800 1.49 37,612 / 1,631,714 2.31 0.67 (0.55-0.81)
Primary Stroke Centers 314 / 17,870 1.76 16,114 / 649,636 2.48 0.77 (0.60-0.98)
Medicare 1,677 / 123,302 1.36 73,412 / 3,144,156 2.33 0.59 (0.52-0.67)
Medicaid 57 / 4,677 1.21 3,866 / 248,126 1.56 0.70 (0.32-1.56)
Private 159 / 10,665 1.49 14,407 / 480,799 3.00 0.51 (0.35-0.76)
Bipolar Disorder
Overall 14,708 11.1% 261,327 5.4% 2.74 (2.69- 2.79)
Teaching hospitals 6,625 / 54,800 12.09 143,870 / 1,631,714 8.82 1.65 (1.52-1.79)
Primary Stroke Centers 2,153 / 17,870 12.05 61,784 / 649,636 9.51 1.50 (1.33-1.69)
Medicare 12,804 / 123,302 10.38 245,802 / 3,144,156 7.82 1.56 (1.47-1.65)
Medicaid 603 / 4,677 12.89 23,520 / 248,126 9.48 1.57 (1.19-2.08)
Private 1,493 / 10,665 14.00 51,210 / 480,799 10.65 1.66 (1.40-1.98)
Depression
Overall 77,697 58.5% 2,469,428 50.8% 1.33 (1.31- 1.34)
Teaching hospitals 12,197 / 54,800 22.26 329,280 / 1,631,714 20.18 1.11 (1.04-1.18)
Primary Stroke Centers 3,863 / 17,870 21.62 130,582 / 649,636 20.10 1.11 (0.99-1.23)
Medicare 24,925 / 123,302 20.21 600,431 / 3,144,156 19.10 1.06 (1.01-1.11)
Medicaid 680 / 4,677 14.55 37,990 / 248,126 15.31 0.99 (0.78-1.24)
Private 2,489 / 10,665 23.33 116,339 / 480,799 24.20 1.02 (0.90-1.15)
Psychosis
Overall 996 0.8% 29,512 0.6% 1.25 (1.17- 1.33)
Teaching hospitals 9,396 / 54,800 17.15 248,402 / 1,631,714 15.22 1.35 (1.26-1.45)
Primary Stroke Centers 2,605 / 17,870 14.58 93,434 / 649,636 14.38 1.10 (0.99-1.24)
Medicare 20,708 / 123,302 16.79 458,054/ 3,144,156 14.57 1.31 (1.24-1.39)
Medicaid 1,918 / 4,677 41.02 76,054 / 248,126 30.65 1.73 (1.42-2.12)
Private 1,578 / 10,665 14.79 50,115 / 480,799 10.42 1.46 (1.25-1.71)
Substance Abuse
Overall 8191 6.2% 301,892 6.2% 1.06 (1.04- 1.09)
Teaching hospitals 4,062 / 54,800 7.41 89,440 / 1,631,714 5.48 1.50 (1.36-1.64)
Primary Stroke Centers 1,896 / 17,870 10.61 41,888 / 649,636 6.45 1.85 (1.62-2.10)
Medicare 8,834 / 123,302 7.16 171,240 / 3,144,156 5.45 1.46 (1.37-1.55)
Medicaid 125 / 4,677 2.67 19,913 / 248,126 8.03 0.32 (0.19-0.53)
Private 940 / 10,665 8.81 27,847 / 480,799 5.79 1.73 (1.46-2.05)
Suicide
Overall 1121 0.8% 49,906 1.0% 0.98 (0.92- 1.04)
Teaching hospitals 679 / 54,800 1.24 40,200 / 1,631,714 2.46 0.61 (0.50-0.74)
Primary Stroke Centers 538 / 17,870 3.01 28,022 / 649,636 4.31 0.80 (0.65-0.99)
Medicare 1,478 / 123,302 1.20 64,408 / 3,144,156 2.05 0.61 (0.53-0.69)
Medicaid 62 / 4,677 1.33 6,438 / 248,126 2.59 0.73 (0.46-1.16)
Private 206 / 10,665 1.93 19,238 / 480,799 4.00 0.63 (0.46-0.87)

** Adjusted for age, sex, payer, admission type *** Adjusted for age, sex, payer, hospital type, admission type; run on 2004-2010 NIS years **** Adjusted for
age, sex, admission type, and hospital type

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Movement Disorders, Vol. 31, No. 12, 2016 1817

psychiatric evaluation when comorbid PD is present,
and a tempering of other disorders or behaviors con-
sistent with overall risk averseness in PD patients. The
limitations of this study include the fact that many
psychiatric illnesses can be effectively treated in the
outpatient setting; therefore, one cannot draw conclu-
sions about the epidemiology of psychiatric illness in
the PD community using these data. Personal, physi-
cian, socioeconomic, and local market factors can
influence whether a patient receives inpatient psychiat-
ric care. Retrospective studies, whether a consisting of
a chart review at an academic center, secondary
review of clinical trial data, or hospital claims data (as
in this case), are subject to recognition, reporting, and
coding bias. Our results may be affected by a misdiag-
nosis of PD, under- or overdiagnosis of psychiatric ill-
ness in PD, coding error, and deliberate miscoding by
physicians or coders to increase revenue. Although our
findings were robust to sensitivity analyses aimed to
detect bias related to hospital and payer characteristics
and we achieved similar results when we did not limit
the MHSA diagnosis by position, we cannot be certain
of the magnitude or direction of these biases. Future
studies should consider the efficacy of coordinated care
between mental health and neurological specialties,
improved recognition of common movement disorders,
and the potential role of anti-PD treatments in older
patients presenting with psychiatric disturbances.

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