POPULATIONS AT RISK
Persistence of Impaired Functioning and Psychological
Distress after Medical Hospitalization for Men with
Co-occurring Psychiatric and Substance Use Disorders
Brenda M. Booth, PhD, Frederic C. Blow, PhD, Cynthia A. Loveland Cook, PhD
OBJECTIVE: To measure the persistence of impaired health-
related quality of life (HRQL) and psychological distress
associated with co-occurring psychiatric and substance use
disorders in a longitudinal sample of medically hospitalized
DESIGN: A random sample followed observationally for 1 year
after study enrollment.
SETTING: Inpatient medical and surgical wards at three
university-affiliated Department of Veterans Affairs Medical
PATIENTS/PARTICIPANTS: A random sample of 1,007 admis-
sions to medical and surgical inpatient services, excluding
women and admissions for psychiatric reasons. A subset of
participants (n = 736) was designated for longitudinal follow-up
assessments at 3 and 12 months after study enrollment. This
subset was selected to include all possible participants with
study-administered psychiatric diagnoses (52%) frequency-
matched by date of study enrollment to approximately
equivalent numbers of participants without psychiatric diag-
MEASUREMENTS AND MAIN RESULTS: All participants were
administered a computerized, structured psychiatric diagnos-
tic interview for 13 psychiatric disorders (including substance
use) and received longitudinal assessments at 3 and 12 months
on a multidimensional measure of HRQL, the SF-36, and a
measure of psychological distress, the Symptom Checklist, 90-
item version. On average, HRQL declined and psychological
distress increased over time (P < .05). Psychiatric disorders
were associated with significantly greater impairments in
functioning and increased distress on all measures (P < .001)
except physical functioning (P < .05). These results were
replicated in the patients (n = 130) who received inpatient or
outpatient mental health or substance abuse services.
CONCLUSIONS: General medical physicians need to evaluate
the mental health status of their hospitalized and seriously ill
patients. Effective mental health interventions can be in-
itiated posthospitalization, either immediately in primary care
or through referral to appropriate specialty care, and should
improve health functioning over time.
KEY WORDS: comorbidity; psychiatric disorders; subs-
tance use disorders; health status; psychological distress;
J GEN INTERN MED 2001;16:57±65.
ndividuals with medical illnesses, especially those using
inpatient or outpatient medical services, experience
high levels of psychological distress and functional impair-
ment at the time of service use.
These reports document
that up to 50% of medically ill patients report substantial
depression, anxiety, or general distress. Furthermore,
psychiatric comorbidity is associated with substantially
higher health care costs for medical illness during hospi-
and in primary care.
Psychiatric comorbidity, whether measured as symp-
tomatology or by psychiatric diagnostic interview, is also
associated with substantial functional impairment in
individuals with medical illnesses.
In individuals with
comorbid serious medical illnesses, these decrements in
functioning have been observed only cross-sectionally or
longitudinally for depression alone.
But we have little
information about the impact of the range of co-occurring
psychiatric disorders on longitudinal functioning for the
broad spectrum of medical illness. This question is
particularly important as health practitioners and health
care organizations are being increasingly asked to provide
information on patient outcomes to employers and other
health care purchasers.
Generally, it is not clear whether the high levels of
distress and reduced functioning associated with a medical
hospitalization and co-occurring psychiatric disorders are
transient circumstances surrounding an acute medical
Received from the HSR&D Center for Mental Healthcare and
Outcomes Research, Central Arkansas Veterans Healthcare
System and Department of Psychiatry, University of Arkansas
for Medical Sciences, Little Rock, Ark (BMB); Serious Mental
Illness Treatment Research and Evaluation Center, HSR&D
Field Program, VA Medical Center and Department of Psychia-
try, University of Michigan, Ann Arbor, Mich (FCB); and the
Center for Social Justice, School of Social Work, St. Louis
University, St. Louis, Mo (CALC).
Address correspondence and reprint requests to Dr. Booth:
HSR&D Center for Mental Healthcare Outcomes and Research
(152/NLR), VA Medical Center, 2200 Fort Roots Dr., North Little
Rock, AR 72114 (e-mail: BoothBrendaM@exchange.uams.edu).