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T
he relationship between mental illness and sexu-
ally transmitted diseases (STDs) is a potentially
important research focus with implications for
prevention programs. A relationship between mental
health conditions and STDs may exist because patients
with complex and varied social and sexual interactions
may experience higher needs for both types of services.
Alternatively, patients with mental health disorders
might exert less conscious control over their sexual
interactions because of feelings of worthlessness, rest-
lessness, boredom, or anxiety.
1
Considerable attention has been directed at under-
standing this relationship within specific subgroups
(adolescents, the indigent, and institutionalized popula-
tions) whose members are at increased risk for acquir-
ing STDs, including human immunodeficiency virus
(HIV).
2-5
Previous studies of publicly insured, institu-
tionalized, or indigent populations have found a rela-
tionship between severe mental health disorders (such
as schizophrenia, bipolar condition, and episodes of
psychosis) and STDs, including HIV infections. Several
studies
1,6-8
have suggested that patients with a range of
behavioral control disorders may be at greater risk for
STDs. A recent study
9
that evaluated a sample of STD
clinic patients in Baltimore found that STD clinic
patients with more severe antisocial personality disor-
ders were at greater risk of STD infection, while those
with comparatively less severe mood and substance
abuse disorders were not. Rates of STDs may also be
higher in privately insured patients who use mental
health services, and the relationship between mental
health and STDs may extend to milder mental health
conditions in addition to severe ones.
A significant amount of STD morbidity occurs in
patients who seek care from private sources. In 2002,
78% of chlamydia cases and 65% of gonorrhea cases
were reported by private clinicians,
10
and 62% of
patients who needed STD care sought it from their pri-
vate clinicians.
11
If an association is found between the
use of STD services and mental health services, this
information could be used to target more efficient STD
prevention services to those patients seeking mental
health treatment. More efficient targeting is important
because significant barriers impede the identification
and proper treatment of STDs in private settings. These
barriers include limited STD knowledge among many
VOL. 10, NO. 12 THE AMERICAN JOURNAL OF MANAGED CARE 917
CLINICAL
Mental Health Disorders and
Sexually Transmitted Diseases in a
Privately Insured Population
David B. Rein, PhD; Lynda A. Anderson, PhD;
and Kathleen L. Irwin, MD, MPH
Objectives: To consider whether patients who use mental
health services in privately insured settings are also more likely to
have received sexually transmitted disease (STD) or human
immunodeficiency virus (HIV) diagnoses and whether this relation-
ship extends to patients with milder mental health disorders.
Methods: Using frequency tables stratified by age and sex, a
logistic regression model, and difference of means tests, we exam-
ined the relationship between mental health claims and STDs in a
sample of 289 604 privately insured people across the United States.
Results: Patients with mental health claims were more than
twice as likely as other patients to have an STD claim in the same
year after controlling for confounding factors (odds ratio, 2.33;
95% confidence interval, 2.11-2.58). This relationship held for
severe and milder mental health diagnoses, for male and female
patients, and in each age category from 15 to 44 years. Among
women, patients aged 20 to 24 years with a mental health claim had
the highest predicted probability of STD diagnoses (3.0%); among
men, patients aged 25 to 29 years with a mental health claim had
the highest predicted probability of STD diagnoses (1.2%).
Conclusions: In this population, patients with mental health
claims were more likely to also have claims with diagnoses for
STDs than patients without mental health claims, and this relation-
ship applied to severe and milder mental health disorders. This
suggests that people with mental health disorders in privately
insured populations may benefit from routine STD risk assessments
to identify high-risk patients for referral to cost-effective preventive
services.
(Am J Manag Care. 2004;10:917-924)
From the Division of Health Economics Research, RTI (Research Triangle Institute)
International, Atlanta, Ga (DBR), and Center for HIV, STD, and TB Prevention, National
Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and
Prevention (CDC), Atlanta, Ga (LAA, KLI).
Portions of Dr Rein’s work were conducted under and supported by the Research
Participation Fellowship Program at CDC, administered by the Oak Ridge Institute for
Science and Education, Oak Ridge, Tenn, through an interagency agreement between the
US Department of Energy and CDC. Additional funding was supplied by RTI International.
Address correspondence to: David B. Rein, PhD, Division of Health Economics
Research, RTI International, 2951 Flowers Road South, Suite 119, Atlanta, GA 30341.
E-mail: drein@rti.org.
private-setting practitioners, low priority given to STD
detection and prevention in many private-sector set-
tings, low patient demand for STD screening and risk
assessment, reimbursement policy–driven financial dis-
incentives for routine sexual risk assessment and STD
screening of asymptomatic patients, and difficulties in
offering care to sex partners who are not enrolled in the
same health plan as the infected index patient.
12,13
National survey data demonstrate that private pri-
mary care providers miss many opportunities to provide
STD, HIV, and pregnancy prevention counseling to
high-risk patients.
14
Still, many private providers do not
believe that STDs are a major issue for the patients they
treat.
15
Some physicians (as opposed to nurse practi-
tioners and physician assistants) may be reluctant to
offer STD preventive services because they doubt the
cost effectiveness of the intervention.
16
Information that
better pinpoints which patients are most likely to need
STD preventive services may make providers more will-
ing to offer such services, particularly if it alters their
beliefs that these services are important and can
improve the cost effectiveness of delivery.
To determine whether administrative data might be
used to target STD risk assessments to mental health
patients, we examined rates of STD diagnoses for
patients who sought mental health services relative to
those who did not, using medical claims data drawn
from a large national set of private commercial health
plans. We also considered whether higher rates of STD
diagnoses exist in privately insured populations with
mental health service utilization for disorders of milder
character (specifically, adjustment disorders), and we
look at differences in these associations by age and sex.
METHODS
We analyzed a subset of 289 604 patients from the
1995 MarketScan
17
database, a national commercial
database of the private insurance claims of more than 5
million people in 1995. The MarketScan database,
although not a probabilistic sample, is drawn from
insurance markets across the United States and has
been used in previously published studies
18,19
of STD
care. To compile the MarketScan database, the Medstat
group purchases health insurance claims and enroll-
ment records from corporations, not-for-profit organiza-
tions, and municipal employers across the United
States; strips personal identifying information (includ-
ing information about patient ethnicity) from the
records; cleans the records for inconsistencies; and
combines them into data files for research use. Each of
the plans in this file used a preferred provider or indem-
nity fee-for-service reimbursement system. Health
maintenance organizations that did not collect
encounter-level claims information were not included
in the data.
We restricted our analyses to enrollees aged 15 to 44
years because this age group has the highest risk of
STDs.
2,3
Additional inclusion criteria included an iden-
tified health plan and reported prescription drug cover-
age information.
In this database, a claim represents a request by a
provider to the patient’s insurer for payment for a spe-
cific service rendered. Each claim is coded with infor-
mation describing the type of service or procedure
rendered by the physician and the diagnosis code indi-
cating the reason this service was required. We identi-
fied patients with mental health diagnoses using
psychiatric diagnosis claims or psychoactive drug pre-
scriptions (International Classification of Diseases,
Ninth Revision, Clinical Modification codes used to
define mental health conditions and STDs are available
as an appendix from the author). Psychiatric claims for
tobacco addiction, autism, or mental retardation were
not considered mental health diagnoses for this analy-
sis.
20
Any patient with at least 1 mental health claim
was classified as having used mental health services. We
classified claims for adjustment disorders as evidence of
a mild mental health condition. Claims for mental
health diagnoses are an imperfect measure of services
rendered because some providers are uncertain of the
diagnosis without further evaluation or testing,
providers may intentionally miscode to protect patient
confidentiality, and services paid by the patient out of
pocket do not generate claims.
We determined cases of STDs by identifying people
with 1 or more claims with a primary diagnosis code of
a bacterial or viral STD. As with mental health claims,
any patient with at least 1 claim coded with a relevant
STD diagnosis was considered to have used STD servic-
es. A claim only for STD services such as STD laborato-
ry tests (that may yield a negative result) was not
sufficient to be classified as an STD diagnosis. In some
cases, providers may intentionally not code certain
services with an STD diagnosis because they are uncer-
tain of the diagnosis without further evaluation and test-
ing, thereby preventing services from appearing on a
medical bill and enhancing confidentiality. For this rea-
son, claims measures of STD services are imperfect
measures of actual STD services and demand. Although
variations in STD diagnostic codes are likely to be
strongly correlated with variations in the underlying
rates of STDs,
18,21
they should not be mistaken for exact
measurements of STDs and should instead be interpret-
ed simply as indicators of demand for STD services.
CLINICAL
918 THE AMERICAN JOURNAL OF MANAGED CARE DECEMBER 2004
To demonstrate the relationship between
having a mental health claim and an STD
claim, we first calculated rates of STD diagno-
sis claims per 100 000 patients, stratified by
age group and sex. To test whether this rela-
tionship was confounded by other variables,
we created a logistic regression model using
the GENMOD procedure in SAS (Version 6.12,
SAS Institute, Cary, NC), with a dichotomous
measure of any STD diagnoses as the depend-
ent variable. We considered that several vari-
ables might confound the relationship of STDs
and mental health service diagnoses. The vari-
ables age, sex, industry of employment, met-
ropolitan statistical area, and subject’s health
plan were selected as independent variables
on the basis of previous research on the deter-
minants of STDs
10,11,22
and the data available
in the analytic file. Industry was used as a
proxy variable for socioeconomic status,
which was not available. The 8 industries
coded in the data are oil and gas extraction;
mining; durable goods manufacturing; non-
durable goods manufacturing; transportation,
communications, and utilities; retail; finance,
insurance, and real estate; and government
(Table 1). The GENMOD procedure analyzed
data represented in a contingency table and fitted linear
models to functions of response frequencies.
23
This
allowed us to control for the effect of dozens of individ-
ual health plans and metropolitan statistical areas, in a
way similar to a fixed-effects model. All potentially con-
founding variables were retained in the model. The
model was then used to predict the probability of an
STD diagnosis with and without a mental health diag-
nosis by age and sex, controlling for a patient’s health
plan, metropolitan statistical area, and industry.
To assess whether STD diagnosis claims are associat-
ed with a later increase in mental health claims, for
each individual we calculated the number of mental
health diagnosis claims filed before and after the first
STD diagnosis during 1995 for those patients with
claims for both STD and mental health diagnoses. A
large increase in the number of mental health service
claims following an STD diagnosis claim would suggest
that the STD diagnosis may to some extent stimulate
demand for the mental health services coded with this
diagnosis. However, if the numbers of mental health
diagnosis claims before and after an STD diagnosis
claim were roughly equal, this would suggest that an
STD diagnosis claim was not the sole stimulus for the
subsequent use of services associated with mental
health diagnoses. Because the monthly timing of indi-
vidual STD diagnoses was likely to be randomly distrib-
uted across the 12 months of 1995, we assumed that the
timing of individual STD diagnoses was not likely to
affect the mean number of claims before and after an
STD diagnosis found at the group level. We tested the
difference in the overall mean number of claims before
and after the first STD diagnosis, using an F test from an
analysis of variance.
Specifically, our methods test the following 3
hypotheses: (1) The rates of STD diagnoses per 100 000
patients differ significantly between those with and
without mental health claims, before adjusting for
potentially confounding variables. (2) Controlling for
potentially confounding variables, people with differ-
ent mental health diagnoses experience statistically
higher probabilities of also having an STD diagnosis.
(3) The mean number of mental health claims does
not differ before and after an STD diagnostic claim
among patients with both STD and mental health diag-
nostic claims.
RESULTS
A total of 36 032 patients (12.4%) had at least 1 claim
for a mental health diagnosis. The most prevalent men-
Mental Health Disorders and STDs
VOL. 10, NO. 12 THE AMERICAN JOURNAL OF MANAGED CARE 919
Table 1. Population Characteristics Used as Control Variables
Control Variable %
Sex
Male 48
Female 52
Age group, y
15-19 20
20-24 19
25-29 15
30-34 12
35-39 14
40-44 19
Industry
Durable goods manufacturing 6
Nondurable goods manufacturing 20
Transportation, communications, and utilities 4
Retail 49
Finance, insurance, and real estate 19
Other < 2
tal health diagnosis claims were related to adjustment
disorders and prescriptions for antidepressant medica-
tions. A total of 1969 patients (0.7%) had at least 1 claim
for an STD diagnosis. The most commonly diagnosed
STDs were genital herpes, human papillomavirus (geni-
tal warts), genital lice, pelvic inflammatory disease (in
women), gonorrhea, nongonococcal urethritis (in men),
and HIV/AIDS (in men because there were no instances
of HIV/AIDS diagnoses in women in this sample). Five
hundred ninety-seven patients had both mental health
and STD diagnosis claims. In terms of population-
based use of medical services, 680 per 100 000 private-
ly insured patients in the overall sample had a claim for
an STD diagnosis, compared with 1657 per 100 000 pri-
vately insured patients who received at least 1 claim for
a mental health diagnosis.
Substantial differences in rates of diagnosis claims
existed between age groups and sexes (Table 1).
Overall, women with a mental health diagnosis claim
were the most likely to have claims with STD diagnoses,
followed by women without a mental health diagnosis
claim, men with such a claim, and men without such a
claim. Significant variation in rates of claims with STD
diagnoses existed by age, generally with younger women
(15-29 years) and older men (25-39 years) exhibiting
higher rates of such claims.
After controlling for potentially confounding vari-
ables in the logistic model, we found that patients with
at least 1 mental health diagnosis claim were more than
twice as likely as patients without such claims to have
had an STD diagnosis claim in the same year (Table 2)
(odds ratio [OR], 2.33; 95% confidence interval [CI],
2.11-2.58). Patients prescribed antidepressant medica-
tions were more than
twice as likely to have
STD diagnosis claims
as patients without
these drug claims (OR,
2.21; 95% CI, 1.92-
2.55). Compared with
other teens aged 15 to
19 years, teen patients
who had mental health
diagnosis claims were
nearly twice as likely
also to have had STD
diagnosis claims (OR,
1.98; 95% CI, 1.50-
2.63).
Patients with claims
for antipsychotic med-
ications, bipolar condi-
tion, and substance
abuse problems had the highest risk of STD diagnosis
claims, but those with milder conditions also had high-
er rates of STD diagnosis claims than those without
these mental health diagnosis claims (Table 3).
Patients diagnosed as having adjustment disorders
were nearly twice as likely to have an STD diagnosis as
patients without adjustment disorders (OR, 1.93; 95%
CI, 1.64-2.28).
These differences in odds translated into higher
absolute probabilities of STD diagnoses for patients with
mental health conditions. No age group of men without
mental health diagnoses had a population prevalence of
STD diagnoses that exceeded 0.3%, and no age group of
women without mental health diagnoses had a popula-
tion prevalence of STD diagnoses that exceeded 1.0%.
In contrast, men with mental health claims had a pre-
dicted population prevalence of STD diagnoses between
0.3% and 1.2%, and women with mental health claims
had a predicted prevalence between 1.2% and 3.0%
(Table 4). The association between STD diagnosis
claims and mental health diagnosis claims was stronger
among women than among men but did not vary appre-
ciably by age. For persons with both mental health and
STD diagnosis claims in the same year, no significant
difference was found between the number of claims for
mental health diagnoses and drugs before (mean, 3.24)
and after (mean, 3.31) a diagnosis of an STD.
DISCUSSION
Our results show a significant relationship between
claims for STD diagnoses and mental health diagnoses.
CLINICAL
920 THE AMERICAN JOURNAL OF MANAGED CARE DECEMBER 2004
Table 2. Rates per 100 000 of Any Sexually Transmitted Disease (STD) Diagnosis
Claims for Patients With and Without Any Mental Health Diagnosis Claims by
Age Group and Sex*
No. of
Mental Health Age Group, y
Diagnosis
Claims 15-19 20-24 25-29 30-34 35-39 40-44 All Ages
0
Women 1138 1212 997 1197 354 818 853
Men 222 295 213 231 261 169 233
≥ 1
Women
2509 3397 2629 1847 1898 1438 2110
Men 313 756 1401 839 1128 809 786
*International Classification of Diseases, Ninth Revision, Clinical Modification codes used to define mental health
conditions and STDs are available as an appendix from the author. χ
2
Tests indicate a significant difference (P < .01)
in the rate of STD diagnoses between those with and without a mental health diagnosis claim for each pair except
men aged 15 to 19.
This was observed in women and men and in all age
groups within the 15- to 44-year age range. Our study
is consistent with other investigations
24
in showing that
the occurrence of an STD diagnosis claim was not asso-
ciated with a later increase in mental health diagnosis
claims. Furthermore, we found an association for
patients with severe mental health disorders and pre-
scriptions, such as bipolar condition and antipsychotic
medications, as well as for patients with milder condi-
tions and prescriptions, such as adjustment disorders
and antidepressant medications.
This association translated into substantially
increased absolute probabilities of STD diagnoses for
patients with mental health diagnoses compared with
patients without such diagnoses. Furthermore, diag-
nosed STDs likely indicate a substantial amount of
undiagnosed disease in the community. A population-
based study
25
of Baltimore, Md, households found that
the number of prevalent undiagnosed gonococcal and
chlamydia infections in adults aged 18 to 35 years
approached or exceeded the number of infections that
were diagnosed and treated annually.
The low prevalence of diagnosed STDs in those
without mental health claims is unlikely to attract the
attention of most plan managers. However, the 1% to
3% prevalence in enrollees with mental health claims
greatly exceeds the yearly rate of new diagnoses for
breast cancer and prostate cancer (approximately
0.3%
26
and 0.2%,
27
respectively, of the over age 40
female and male populations), both of which are rou-
tinely screened for in private settings. Routine chlamy-
dia screening of sexually active women 26 and younger
was ranked as a better prevention value than mammog-
raphy in a recent ranking of preventive services based
on burden of disease prevented and cost-effectiveness of
the service.
28
This study may be limited by possible miscoding of
STDs and mental health claims that was unintentional
or intentional (eg, because the diagnosis was uncertain
or to protect patient confidentiality). In addition, the
association between mental health and STD claims may
be confounded by other variables, specifically race, for
which data were not available. In addition, because the
timing of STD diagnoses was not retained in the data
analysis file, we assumed that STD diagnoses were nor-
mally distributed throughout the year. Conclusions
drawn from the difference in the mean number of
claims before and after a mental health diagnosis rely
on the validity of this assumption.
Substance abuse may play a larger role in driving the
relationship between mental health and STD diagnoses
than is apparent from these claims data. Like STDs,
substance abuse disorders may not be coded at all or
may be intentionally miscoded as milder mental health
conditions such as adjustment disorders to protect
patient confidentiality. Clinical follow-up studies of this
work should attempt to collect information on sub-
stance use behaviors to separate (to the extent possible)
the disinhibiting effect of inebriation on the behaviors
that lead to STDs from the effect of mental health dis-
orders alone. In these data, patients with diagnosed
substance abuse problems were not driving the rela-
tionship between mental health and STD diagnoses.
First, only 2.9% of the group with mental health diag-
noses had claims only for substance abuse problems
with no other mental health condition diagnosed.
Second, patients with mental health diagnoses other
than substance abuse also experienced higher rates of
STD diagnoses (Table 2).
Our findings may not be generalizable to populations
that tend to be less affluent or experience a higher inci-
dence of bacterial and viral STDs.
9,29
In addition, the
1995 data used in this study may not be representative
of populations today because of different clinical and
claims-coding practices for mental health and STD serv-
ices. Future research should be conducted to verify
these results using more recent data. This research
should use a longitudinal design to better address issues
of causality between STDs and mental health disorders
Mental Health Disorders and STDs
VOL. 10, NO. 12 THE AMERICAN JOURNAL OF MANAGED CARE 921
Table 3. Association Between Claims for Mental
Health Diagnoses and Claims for Sexually
Transmitted Disease (STD) Diagnoses by Type of
Mental Health Diagnosis Claim*
Odds Ratio
Claim Type (95% Confidence Interval)
Any mental health diagnosis 2.33 (2.11-2.58)
or prescription
Bipolar condition 2.62 (2.14-3.21)
Substance abuse 2.60 (1.78-3.80)
Personality disorder 2.09 (1.78-2.47)
Adjustment disorder 1.93 (1.64-2.28)
Schizophrenia 0.88 (0.28-4.56)
Psychiatric service in teens† 1.98 (1.50-2.63)
Antipsychotic medication 2.90 (2.24-3.76)
Antianxiety medication 2.42 (2.07-2.82)
Antidepressant medication 2.21 (1.92-2.55)
*Adjusted for age, sex, industry of employment, metropolitan statistical area,
and subject’s health plan. The reference group is patients without a given
mental health diagnosis claim. International Classification of Diseases,
Ninth Revision, Clinical Modification codes used to define mental health
conditions and STDs are available as an appendix from the author.
†
Among teens aged 15 to 19 years (n = 47 621).
and should assess the cost effectiveness of targeting
STD/HIV risk assessments to privately insured people
who use mental health services.
However, although additional studies on this subject
using newer data are needed, the theory that mental
health disorders may contribute to behaviors that result
in STDs is still valid. Furthermore, our findings are con-
sistent with more recent nonclaims data showing a sim-
ilar relationship in an STD clinic setting.
9
Our ability to
observe this relationship may be even stronger today
than in 1995 for several reasons. If the enactment of the
Mental Health Parity Act of 1996 resulted in greater pri-
vate insurance coverage of mental health services, it
may have increased the number of people with mental
health disorders who can be identified using inexpen-
sive, targeted STD risk assessment. Second, the delivery
of STD services in private settings has likely increased
since 1995 because of the expansion of Medicaid man-
aged care, the advent of the State Child Health Insurance
Program, and the elimination of many publicly funded
STD clinics; this last reason has likely pushed more peo-
ple to seek care from private providers. These changes
have likely increased the number of patients at high risk
for STDs seen in private settings, thus increasing the
need for and the potential effectiveness of STD risk
assessments in private settings as well. Although ideally
this research should be replicated with more recent
data, the core findings seem unlikely to change.
Many private-sector providers still believe that rou-
tine sexual risk assessment is a low priority for their
patients or avoid conducting risk assessments because
they believe their patients have a low prevalence of
STDs (a belief that may not be supported by data
10,11
)
because face-to-face risk assessment makes some
providers or patients
feel uncomfortable or
because some insurers do
not reimburse adequate-
ly for risk assessments.
However, our data
suggest that, for patients
with mental health con-
ditions, STD risk assess-
ment is warranted, and
health systems and
providers should attempt
to identify methods to
implement it routinely.
Improvements in pri-
mary care STD/HIV risk
assessment can be
achieved in outpatient
settings using inexpen-
sive interventions
30
such
as patient self-assessment forms, nonphysician coun-
selors, education pamphlets, or videos. Examples of
patient self-assessment tools can be accessed on the
Internet.
31,32
Routine risk-assessment questions can be integrated
into existing patient forms and questionnaires at negli-
gible cost to the provider or the insurer. Based on stud-
ies of other interventions to prevent STDs, targeted
low-cost risk assessments are likely to be cost effective
for the provider, given the proven cost effectiveness of
targeted STD preventive services.
For example, research has found that screening for
asymptomatic Chlamydia trachomatis with a nucleic
acid amplification–based test is cost-effective in female
populations with prevalences as low as 1.1%.
33
Other
research has shown that most cost savings associated
with treating asymptomatic chlamydial infections likely
accrue within the same year.
34
In women, undiagnosed
low-cost bacterial infections may develop into acute
cases of pelvic inflammatory disease with costs between
$1060 and $1410 per case.
35
In the population of rough-
ly 23 000 women with mental health diagnoses
observed in these data, 244 cases of pelvic inflammato-
ry disease were diagnosed, compared with only a com-
bined 44 cases of diagnosed gonorrhea and chlamydia,
suggesting that targeted bacterial STD screening based
on risk assessments would have likely improved health
outcomes and generated savings. Treatment of most
STDs detected early in the course of infection is inex-
pensive, usually involving 1 to 7 days of antibiotic treat-
ment. Treatment of upper genital tract complications of
untreated lower genital tract infection such as pelvic
inflammatory disease, ectopic pregnancy, and infertility
CLINICAL
922 THE AMERICAN JOURNAL OF MANAGED CARE DECEMBER 2004
Table 4. Predicted Percent With Any Sexually Transmitted Disease (STD)
Diagnosis Claims for Patients With and Without Any Mental Health Diagnosis
Claims by Age Group and Sex*
No. of Age Group, y
Mental Health
Diagnosis Claims 15-19 20-24 25-29 30-34 35-39 40-44 All Ages
0
Women 0.9 1.0 0.8 0.9 0.8 0.6 0.9
Men 0.3 0.3 0.2 0.3 0.2 0.2 0.2
≥ 1
Women 2.2 3.0 2.2 1.8 1.7 1.2 2.1
Men 0.3 0.6 1.2 0.7 0.6 0.6 0.6
*Adjusted for age, sex, industry of employment, metropolitan statistical area, and subject’s health plan. International
Classification of Diseases, Ninth Revision, Clinical Modification codes used to define mental health conditions and
STDs are available as an appendix from the author.
is more costly; this underscores the potential value of
early STD detection through risk assessment and refer-
ral to preventive screening and other services of high-
risk patients. Even costly diseases such as HIV/AIDS
are less costly to manage when identified early.
Research has demonstrated that early detection and
proper management of HIV prevent many of the high-
cost inpatient admissions associated with acute symp-
tomatic AIDS.
36
At the insurance plan level, administrative claims
information could be used to target STD preventive
services to specific high-risk individuals. Insurers could
recommend sexual risk assessments and referrals to
screening and services for those at risk as elements of
their standard mental health care. Mental health claims
could also be used to trigger mechanisms (such as con-
fidential personalized communication) that target spe-
cific patients for STD/HIV risk assessment based on
their use of mental health services. Such policies are
ethical and legal under current regulations, provided
the information that is already available to the plan’s
benefit managers and participating providers is being
used to enhance patient health and is administered
confidentially and with sensitivity. Legally, federal
Health Insurance Portability and Accountability Act
regulations specifically allow the within-plan use of
patient administrative health information to target pre-
ventive care (D. Magid, MD, oral communication,
2004).
37
Sexually transmitted disease screening interven-
tions have been shown to improve health while saving
costs in several clinical and nonclinical settings.
33,34,36
The 2 primary determinants of the cost effectiveness of
these interventions were the disease prevalence and
the intervention cost: the higher the STD prevalence
and the lower the cost of the intervention, the greater
the benefits of the intervention. Anecdotal reports sug-
gest that sexual health issues are not generally a con-
cern for medical groups, psychiatric groups, or
hospitals. This is perhaps justified because, before this
study, no published literature addressed the question of
whether the prevalence of STD diagnoses in privately
insured populations would economically justify preven-
tive health interventions. However, this article demon-
strates a prevalence of STD diagnoses in the
subpopulation of privately insured patients with mental
health diagnoses or using psychoactive prescriptions
that exceeds the disease prevalence at which other STD
interventions were found to be cost effective.
33,34,36
Furthermore, current STD policy makers argue that
mental health systems should implement simple refer-
ral systems to facilitate routine STD care and screen-
ing.
38
Although our data are from 1995, we have reason
to believe the relationship between mental health diag-
noses and STDs remains true.
9-11,14,22
Given our results, we suggest that patients with
mental health disorders between the ages of 15 and 44
years be routinely assessed for STD/HIV risks, particu-
larly in areas of the country where the overall popula-
tion prevalence of STDs is high. This recommendation
is likely to be particularly useful in targeting services
toward women, especially those between the ages of 15
and 29. Health systems and providers should consider
how confidential use of claims data could facilitate the
targeting of patients with mental health diagnoses who
may benefit from STD/HIV risk assessment.
Acknowledgments
We thank Terry Chorba for his helpful review and Sharon Barrell for
her editorial support.
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