Does funding respond to changes in the prevalence diabetes and depression? Differences across states

Background. It is important to understand the extent of co-occurrence of depression and diabetes because diabetes can worsen mental health (e.g., increase stress, make it hard to make choices like what to eat, how and when to have social interactions) and mental health can affect diabetes management (e.g., depression decreases interest in physical activity and worse adherence to treatment). Objective. This study shows the extent to which mental health and diabetes are correlated and what individual and systems-level factors are associated with co-occurrence. The first order question in this paper is to understand if the co-occurrence of depression and diabetes is higher in states that have had historically little funding? To compare the efforts of individual states to provide adequate care for individuals with mental illness we use two measures: (1) per capita mental health expenditures by states and (2) the percentage of total state government expenditures that is allocated for mental health programs. Because states have different socio-demographic compositions that would contribute to both lower funding for healthcare services and a higher prevalence of chronic conditions, this paper also seeks to explore how spending at the state level has responded to changes in the prevalence of diabetes and depression. In an ideal world, production and dissemination of prevalence data from the CDC and data on healthcare spending from CMS and private insurers should inform the national and state-level funding portfolio. Methods. We use the latest 5 rounds in BRFSS data to model diabetes and depression as bivariate distributions, controlling for sex, age, race, marital status, insurance, employment, exercise, smoking, and drinking. This allows is to obtain state-level estimates for the co-occurrence of diagnosed diabetes and depression. We correlate the co-occurrence of with changes in mental health service expenditures from SMHA. Results. We find that the correlation between diabetes and depression is 17% and statistically significant. There are however vast differences across states in the prevalence of diabetes and depression. Depression alone is more prevalent than diabetes across all states. Age and BMI are the two most important factors in increasing the probability of having both diabetes and depression. The likelihood of joint prevalence is inversely related to the percentage of total state expenditure allocated to mental Illness. In Alabama, Arkansas, Kentucky, and West Virginia, more than 25% of the population has diabetes, depression or both but in these states, less than 1% of their health dollars are allocated to mental health. Co-occurrence is strongly correlated with lack of funding and services for mental health. Quality improvement initiatives may be more successful if targeted to areas where both diabetes and behavioral health issues are high and where there are limited resources dedicated to mental health services. Changes in funding however do not respond to changes in the reported prevalence of these two conditions suggesting that considerations other than need enter in plan when agencies make funding decisions.