Out-of-pocket expenditure burdens in patients with cardiovascular conditions and psychological distress: a nationwide cross-sectional study Yasuyuki Okumura, Ph.D. ⁎, Hiroto Ito, Ph.D. Department of Social Psychiatry, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan abstract article info Article history: Received 1 October 2012 Revised 3 December 2012 Accepted 31 December 2012 Keywords: Burden of disease Resource allocation Mental health policy Equity in health Objectives: This study aimed to estimate the prevalence of psychological distress in individuals with and without cardiovascular risks and events [cardiovascular disease (CVD) conditions] and the incremental effects of psychological distress on the out-of-pocket health care expenditure burdens. Methods: We used data from the Comprehensive Survey of Living Conditions 2007, a nationally representative cross-sectional survey in Japan. Psychological distress assessed by the K6 scale, the presence of treated CVD conditions and out-of-pocket health care expenditures as a share of household consumption expenditures were self-reported by 20,763 individuals living alone and aged between 20 and 59 years. Results: Individuals with obesity [adjusted odds ratio (AOR), 4.3], stroke (AOR, 3.2), ischemic heart disease (AOR, 2.3), hyperlipidemia (AOR, 1.8) or diabetes (AOR, 1.7) were more likely than those without to have serious psychological distress (SPD). With the exception of ischemic heart disease, less than half of CVD patients comorbid with SPD received treatment for mental illness. Patients comorbid with SPD and obesity (AOR, 6.1), SPD and ischemic heart disease (AOR, 3.4), and SPD and hypertension (AOR, 2.6) had higher out- of-pocket burdens than patients with only CVD conditions. Conclusions: Our findings suggest the need for physicians to identify and manage SPD in patients with CVD conditions and for policymakers to find solutions to reduce the high out-of-pocket burdens among these patients. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Cardiovascular risks and events [cardiovascular disease (CVD) conditions] such as obesity, hyperlipidemia, hypertension, diabetes, ischemic heart disease and stroke have been major public health concerns around the world [1]. Individuals with CVD conditions are about twice as likely to suffer from depression, anxiety and psychological distress as those without the conditions [2–4]. These comorbidities remain significant individual and public health con- cerns because they lead to poor quality of life [4], nonadherence to cardiac medication [5], excess direct medical costs [6], productivity loss due to absence from work [7] and increased mortality [8]. Available evidence on comorbidities of CVD conditions with psychological distress and their negative consequences has several limitations. First, few studies, most of which were conducted in the United States, have used nationally representative samples to establish unique associations between the presence of psychological distress and particular CVD conditions [3,9–14]. Second, it remains uncertain whether comorbidities of CVD conditions with psycholog- ical distress are associated with burdens of out-of-pocket health care expenditures relative to effective income. Identifying high out-of- pocket burdens is important because these burdens may be associated with delaying or foregoing medical care for financial reasons [15], which in turn may lead to severe health conditions. Generally, out-of- pocket burden in Japan is lower than other countries [16] because Japan has a universal health care system that reduces out-of-pocket health care expenditures to less than 30% of medical fees. Even in countries where health care systems provide excellent population health at low cost with equity [17], we hypothesized that there would be an incremental effects of psychological distress on out-of-pocket burdens because psychological distress leads to excess direct medical costs and productivity loss [6,7]. In the present study, we used data from a nationally representative sample of 20- to 59-year-old individuals living alone. We had two specific objectives for the present study. First, we examined whether the prevalence of psychological distress was higher in individuals with CVD conditions than in those without CVD conditions. Second, we examined whether out-of-pocket health care expenditures as a share of household consumption expenditures were higher in individuals with psychological distress than in those without. General Hospital Psychiatry 35 (2013) 233–238 ⁎ Corresponding author. Tel.: + 81 42 346 2046; fax: +81 42 346 2047. E-mail address: yokumura@ncnp.go.jp (Y. Okumura). 0163-8343/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2012.12.013 Contents lists available at SciVerse ScienceDirect General Hospital Psychiatry journal homepage: http://www.ghpjournal.com