Utilization of health and mental health services by Los Angeles Mexican Americans and non-Hispanic whites

Issues behind the Utilization of Community Mental Health Services by Ethnic Minorities in Hong Kong

This study collected data on the utilization rates of community mental health services among ethnic minorities and explained the results from the frontline social workers' perspective. Information about users' ethnicity was collected from 11 community mental health service providers from 2015 to 2018. This was followed by two sessions of focus groups conducted with 10 frontline social workers from six community mental health centers in Hong Kong. A hybrid analysis model was employed to analyze the qualitative data. The average utilization rates of community mental health services by ethnic minorities were 0.49%, 0.58%, and 0.68% in the years 2015-16, 2016-17, and 2017-18, respectively, showing that ethnic minorities who comprised 8% of the population were significantly underrepresented. It is worth noting that supply-side and demand-side factors are interrelated, suggesting the low utilization rate may be overcome by implementing a proactive social work service strategy.

Prenatal ambient air pollution and maternal depression at 12 months postpartum in the MADRES pregnancy cohort

BACKGROUND

Depression is the leading cause of mental health-related morbidity and affects twice as many women as men. Hispanic/Latina women in the US have unique risk factors for depression and they have lower utilization of mental health care services. Identifying modifiable risk factors for maternal depression, such as ambient air pollution, is an urgent public health priority. We aimed to determine whether prenatal exposure to ambient air pollutants was associated with maternal depression at 12 months after childbirth.

METHODS

One hundred eighty predominantly low-income Hispanic/Latina women participating in the ongoing MADRES cohort study in Los Angeles, CA were followed from early pregnancy through 12 months postpartum through a series of phone questionnaires and in-person study visits. Daily prenatal ambient pollutant estimates of nitrogen dioxide (NO2), ozone (O3), and particulate matter (PM10 and PM2.5) were assigned to participant residences using inverse-distance squared spatial interpolation from ambient monitoring data. Exposures were averaged for each trimester and across pregnancy. The primary outcome measure was maternal depression at 12 months postpartum, as reported on the 20-item Center for Epidemiologic Studies-Depression (CES-D) scale. We classified each participant as depressed (n = 29) or not depressed (n = 151) based on the suggested cutoff of 16 or above (possible scores range from 0 to 60) and fitted logistic regression models, adjusting for potential confounders.

RESULTS

We found over a two-fold increased odds of depression at 12 months postpartum associated with second trimester NO2 exposure (OR = 2.63, 95% CI: 1.41-4.89) and pregnancy average NO2 (OR = 2.04, 95% CI: 1.13-3.69). Higher second trimester PM2.5 exposure also was associated with increased depression at 12 months postpartum (OR = 1.56, 95% CI: 1.01-2.42). The effect for second trimester PM10 was similar and was borderline significant (OR = 1.58, 95% CI: 0.97-2.56).

CONCLUSIONS

In a low-income cohort consisting of primarily Hispanic/Latina women in urban Los Angeles, we found that prenatal ambient air pollution, especially mid-pregnancy NO2 and PM2.5, increased the risk of depression at 12 months after childbirth. These results underscore the need to better understand the contribution of modifiable environmental risk factors during potentially critical exposure periods.

Epidémiologie de la dépression : données récentes I. Epidémiologie descriptive

Les auteurs font la revue des études récentes concernant l’épidémiologie de la dépression. Les études épidémiologiques de la dépression dans la population générale sont difficiles à interpréter, du fait de différences dans l'identification des cas et de variations dans les procédures de diagnostic entre les études. Mais il y a eu un progrés considérable avec le récent développement des méthodes d’identifications de cas, fiables et valides, comme les RDC et le DSM-III. D’autres problémes méthodologiques concernent le choix de la population et le choix des différentes mesures du risque.

Des données examinées, on peut tirer les estimations suivantes : la prévalence sur six mois de la dépression majeure est de 1% à 3% chez l’homme, et 3% à 5% chez la femme; la prévalence sur la vie entiere (proportion des sujets qui ont déjà présenté le trouble) est de 3% à 6% chez l’homme et 5% à 10% chez la femme. L’estimation du risque morbide (ou risque sur la vie entiére) est plus difficile. Le principal probléme provient de l’effet de cohorte de naissance: il semble que les taux de troubles affectifs majeurs sont en train d’augmenter dans les cohortes nées apres la Seconde Guerre mondiale.

Aussi, les auteurs proposent une estimation des risques sur la vie entiére qui ne peut être que prudente: 6 à 10% chez l’homme, 12 à 20% chez la femme. Ils envisagent aussi l’épidemiologie de la dépression sous l’angle de la mortalité: les troubles affectifs sont associés non seulement à un haut risque de suicide mais aussi à une mortalité générale augmentée.

Epidémiologie de la dépression: données récentes. II — Epidémiologie analytique et épidémiologie d’évaluation

Les données provenant d’études récentes concernant l’épidémiologie analytique et l’épidémiologie d’évauation de la dépression sont examinées.

Au sujet de l’épidémiologie analytique, il peut être conclu de la littérature actuellement disponible que les principaux facteurs de risques pour la dépression majeure sont : a) Sociodémographiques, à savoir : être une femme, être jeune, séparé, divorcé, ou avoir des problèmes conjugaux (les auteurs soulignent en particulier que les différences entre les sexes, concernant la dépression, sont réelles et ne sont pas un artefact lié à la façon de relater les troubles ou au comportement vis-à-vis des soins), b) Environnementaux: facteurs prédisposants (les événements de vie qui surviennent durant l'enfance peuvent prédisposer un individu à la dépression à l’âge adulte) et facteurs précipitants (il y a relation entre la survenue d’événements de vie pendant la vie adulte et le début de la dépression), c) Familiaux: il y a une multiblication par 2 à 5 du taux de dépression majeure chez les parents de premier degré de sujets témoins par rapport à es témoins non malades. L’influence de l’hérédité génétique est supportée par des études de jumeaux et des études adoption, mais une large part de la variance ne peut être expliquée, d) Divers: qui concernent le cycle de reproduc- 10n de la femme (la période du post partum entraîne une augmentation du taux de dépression) et les variations saisonneres (pics au printemps et en automne).

En ce qui concerne l'épidémiologie d’évaluation, il est habituel de distinguer prévention primaire, secondaire et teriaie. Leur dessein est respectivement de diminuer l’incidence de la dépression, la prévalence de la dépression et les isques de chronicité et de la récurrence. Les efforts concernant la prévention primaire ne peuvent avoir qu’un effet imité. Dans le domaine de la prévention secondaire, il peut être conclu que beaucoup de dépressifs ne sont pas diaglostiqués ou ne sont pas traités. La prévention tertiaire a pour dessein de limiter deux risques: la chronicité et la récurence. Le premier pourrait être évalué à 15-20% à chaque épisode. Les facteurs de risques principaux seraient la présence un trouble psychiatrique non affectif ou d’une affection physique, une personnalité névrotique et un faible niveau le traitement. Pour le risque de récurrence, on peut considérer qu’entre 50 et 85% des patients ayant fait un épisode lépressif majeur feront au moins un autre épisode de dépression ultérieurement. Les facteurs de risques pourraient re un Stand nombre d’épisodes antérieurs, un antécédent d’épisode maniaque ou d’hypomanie, l’association à un ésordre psychiatrique non affectif ou à une affection physique, une histoire familiale de maladie affective ou un âge e début tardif.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

Predicting Women’s Utilization of Primary Care Mental Health Services in Mexico City

Objective: To analyze factors associated with and predicting Mexican women seeking primary care mental health services (PCMHS) and provide suggestions to increase PCMHS utilization. Method: We administered a questionnaire to (N = 456) female patients in Mexico City primary care clinics. We conducted chi-square analyses of seeking PCMHS and sociodemographic variables, perceptions of and experiences with PCMHS. Our results and literature review guided our logistic regression model. Results: Women referred to a mental health provider (MHP; odds ratio [OR] = 10.81, 95% CI = 3.59-32.51), whose coping mechanisms included talking to a MHP (OR = 5.53, 95% CI = 2.10-14.53), whose primary worry is loneliness (OR = 8.15, 95% CI = 1.20-55.10), and those who follow doctor’s orders; were more likely to seek PCMHS (OR = 0.28, 95% CI = 0.09-0.92). Conclusions: Primary care providers play a fundamental role in women’s decisions to seek PCMHS. Proper referrals to PCMHS should be encouraged.

Patterns of Rural Hispanic and Non-Hispanic White Health Care Use

This cross-sectional study examines utilization of health care resources, including nursing homes, among 1,433 rural Hispanic and non-Hispanic White participants in the San Luis Valley Health and Aging Study. Results show substantially greater non-Hispanic White residence in nursing homes, greater Hispanic use of professional home nursing services, but little ethnic difference in outpatient care or hospitalization. Analyses based on the behavior model of utilization find health care use strongly associated with need factors. In particular, outpatient care correlated with disease and instrumental daily living activity dependence, home nursing care with basic daily living activity dependence, and nursing home use with daily living activity dependence and cognitive impairment. Predisposing characteristics (age, marital status, education) and enabling supports and barriers (insurance, availability of no-or low-cost care, transportation difficulties) also influenced utilization. The differential ethnic pattern of nursing home use persisted after controlling for these important characteristics.

Childhood Sexual Abuse among Hispanic and Non-Hispanic White College Women

This study is thefirst to describe childhood sexual abuse (CSA) experiences of Hispanic and non-Hispanic White college women. There were no significant ethnic differences in the prevalence of CSA reported by Hispanics (2 7.1%) and non-Hispanic Whites (33.1%). Although the Hispanic women reported CSA that was more serious on almost every dimension (e.g., beginning at a younger age, more physically intrusive), no significant ethnic differences were found on severity nor on numerous other aspects of the CSA. A significantly greater proportion of Hispanic women reported that the perpetrators of their CSA were extended family members, as opposed to nuclear or extrafamilial perpetrators, than did non-Hispanic White women. Non-Hispanic Whites were more likely than Hispanics to indicate that nothing happened as a result of disclosing their CSA.

Automated Screening for Depression: Toward Culturally and Linguistically Appropriate Uses of Computerized Speech Recognition

The feasibility of using computers with speech recognition capability in screening for depression was examined. Computerized and written forms of the Center for Epidemiological Studies-Depression (CES-D) scale were administered to 19 Spanish-speaking and 19 English-speaking primary care medical patients (n = 38) at a hospital-based outpatient depression clinic. A counterbalanced experimental design was employed to randomly assign the order of administration to the language groups. Psychometric analyses of the two methods suggested that the two forms were highly equivalent in both languages. There were no significant differences in the means and variances of the two forms. Ranked-order correlations and coefficient alpha estimates for interitem consistency were high. The two methods were found to be acceptable in equal proportionsfor both language groups, with a tendency to prefer the computerized method.

Psychotherapist Bias with Hispanics: An Analog Study

This study used an innovative analog design to explore the influence of ethnicity on psychotherapists' clinical judgment. A total of 56 non-Hispanic White psychologists viewed one of two videotapes of a mock intake session that were identical exceptfor client ethnicity. The client was depicted with white skin color speaking standard English (non-Hispanic White guise) in one. In the other, the same actress appeared with dark skin color speaking English with a Hispanic accent (Hispanic guise). MANOVA indicated significantunivariate effects of ethnic guise on ratings ofprognosis with treatment, ability to empathize with the client, and blunted affect. Poor prognosis, lower empathy, and greater blunted affect were associated with the Hispanic ethnic guise.

Community Mental Health Services for Hispanics: A Test of the Culture Compatibility Hypothesis

It has been reported repeatedly thatHispanics underuse available mental health services because those services were not compatible with Hispanic culture. Data collected and presented in an earlier study were further analyzed to determine whetherHispanic clients remained in treatment longer if they were served by Hispanic staffandlor at an Hispanic community mental health center. These clients were found to have lower dropout rates and to have received more individual therapy, than did those who received services from non-Hispanic personnel and/or agencies. The implications of these findings for enhancing the use of mental health services by Hispanics are discussed.

Cultural Aspects of Caring for Mexican-American Clients

Cultural factors greatly influence the Mexican-American individual's perception of health, illness and acceptable care regimens. Population projections indicate that Hispanics, a majority of which are Mexican–Americans, will become the largest minority group in the United States. Family structure, health/illness beliefs and traditional health practices can affect the client's acceptance and compliance with prescribed health care regimens. Mexican-Americans will be influenced by cultural sensitivity, access and costs when choosing a health care provider. Nurses need to understand and recognize the importance of providing culturally appropriate care to a rapidly increasing Mexican-American population.

Disparities in Treatment and Service Utilization Among Hispanics and Non-Hispanic Whites with Bipolar Disorder

OBJECTIVES

Due to the serious and recurrent nature of bipolar disorder, continuous long-term medication treatment is typically recommended. Little is known about whether these treatment recommendations are effectively implemented for Hispanics. This study examined differences in mood stabilizer use and mental health service utilization between adult English-speaking Hispanic and non-Hispanic white respondents with bipolar disorder.

METHODS

The sample included 163 participants with lifetime bipolar I and II disorders in the National Comorbidity Survey Replication. Demographics, symptom presentation, and acculturation were examined as covariates.

RESULTS

None of the 26 Hispanic respondents were taking mood-stabilizing medication, compared to 21 % of non-Hispanic whites, and Hispanics were less likely to receive medications for emotional problems, see a professional for manic episodes, or attend psychotherapy. Even after accounting for differences in symptom profiles and sociodemographics, ethnicity continued to be a significant predictor of mood stabilizer use and psychotherapy attendance. There was a non-significant trend toward lower acculturation among Hispanics being associated with even poorer service utilization.

CONCLUSIONS

No Hispanics were receiving minimally adequate treatment for their bipolar disorder. Future research should focus on identifying the barriers that lead to these stark ethnic disparities in treatment.

A mental health intervention strategy for low-income, trauma-exposed Latina immigrants in primary care: A preliminary study

Latinos in the United States face significant mental health disparities related to access to care, quality of care, and outcomes. Prior research suggests that Latinos prefer to receive care for common mental health problems (e.g., depression and anxiety disorders) in primary care settings, suggesting a need for evidence-based mental health services designed for delivery in these settings. This study sought to develop and preliminarily evaluate a mental health intervention for trauma-exposed Latina immigrants with depression and/or posttraumatic stress disorder (PTSD) for primary care clinics that serve the uninsured. The intervention was designed to be simultaneously responsive to patients' preferences for individual psychotherapy and to the needs of safety-net primary care clinics for efficient services and to address the social isolation that is common to the Latina immigrant experience. The resulting intervention, developed on the basis of findings from the research team's formative research, incorporated individual and group sessions and combined evidence-based interventions to reduce depression and PTSD symptoms, increase group readiness, and improve perceived social support. Low-income Latina immigrant women (N = 28), who screened positive for depression and/or PTSD participated in an open pilot trial of the intervention at a community primary care clinic. Results indicated that the intervention was feasible, acceptable, and safe. A randomized controlled trial of the intervention is warranted. (PsycINFO Database Record

Problem drinking by race and nativity: what is learned from social structural and mental health-related data of US-born and immigrant respondents?

BACKGROUND AND OBJECTIVES

 Although heavy drinking is considered a health risk, research demonstrates that some adults turn to alcohol in an effort to manage disabling stress or mental health problems. Race and nativity may be associated with such decisions to "self-medicate" with alcohol. This study identified and compared links between problem drinking and social structural and mental health-related factors for four race-nativity groups.

METHODS

 Using data from the 2009 National Health Interview Survey, the final sample comprised 7,905 US-born Whites, 390 foreign-born Whites, 2,110 US-born Blacks, and 193 foreign-born Blacks. Investigated were the social structural variables of demographic factors (age, gender), socioeconomic status (employment, income, education), and social integration factors (family size, living with a partner). Mental health-related variables included chronic mental illness and access to and use of mental health services.

RESULTS

 Overall, both types of variables were found to be associated with large-quantity drinking and frequent binging, with the strength of association varying-for some factors-by race and/or nativity. Further, the findings indicated that, in the presence of chronic mental illness, both US- and foreign-born Black Americans engaged in relatively frequent binge-drinking when health-care variables were controlled.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

 These results underscore the need for mental health professionals to identify co-occurring mental illness and alcohol abuse among Black clients and, where it is found, to seek the root causes of the persistent stress that tends to accompany this co-occurrence.

The use of clinical trials in comparative effectiveness research on mental health

OBJECTIVES

A large body of comparative effectiveness research (CER) focuses on the use of observational and quasi-experimental approaches. We sought to examine the use of clinical trials as a tool for CER, particularly in mental health.

STUDY DESIGN AND SETTING

Examination of three ongoing randomized clinical trials in psychiatry addressing issues that would pose difficulties for nonexperimental CER methods.

RESULTS

Existing statistical approaches to nonexperimental data appear insufficient to compensate for biases that may arise when the pattern of missing data cannot be properly modeled such as when there are no standards for treatment, when affected populations have limited access to treatment, or when there are high rates of treatment dropout.

CONCLUSION

Clinical trials should retain an important role in CER, particularly in cases of high disorder prevalence, large expected effect sizes, difficult-to-reach populations, or when examining sequential treatments or stepped-care algorithms. Progress in CER on mental health will require careful consideration of appropriate selection between clinical trials and nonexperimental designs and on allocation of research resources to optimally inform key treatment decisions for each patient.

Examining lifetime episodes of sadness, help seeking, and perceived treatment helpfulness among US Latino/as

This study investigated episodes of sadness, help seeking for episodes of sadness, and perceived treatment helpfulness among Latino/as. Specifically, we examined whether gender, ethnicity, and other socio-cultural variables predicted episodes of sadness, help seeking, and treatment helpfulness. Data were taken from the National Latino Asian American Study which included service use questions for episodes of sadness. We stratified the data by service provider and used multiple logistic regressions as analytic strategy. Latinas had higher rates of episodes of sadness than Latinos, and everyday discrimination was positively associated with sadness. Acculturation was associated with more help seeking. Puerto Ricans had the highest rates of help seeking, and Mexican-Americans the lowest. Discrimination was the strongest predictor of treatment helpfulness from any professional as individuals with discriminatory experiences found services less helpful. Interventions need to address cultural factors but more focus needs to be placed on policies that seek to eliminate inequalities.

Mental health needs and service utilization by Hispanic immigrants residing in mid-southern United States

PURPOSE

This study assessed mental health needs and service utilization patterns in a convenience sample of Hispanic immigrants.

DESIGN

A total of 84 adult Hispanic participants completed a structured diagnostic interview and a semistructured service utilization interview with trained bilingual research assistants.

RESULTS

In the sample, 36% met diagnostic criteria for at least one mental disorder. Although 42% of the sample saw a physician in the prior year, mental health services were being rendered primarily by religious leaders. The most common barriers to service utilization were cost (59%), lack of health insurance (35%), and language (31%). Although more women than men met criteria for a disorder, service utilization rates were comparable. Participants with a mental disorder were significantly more likely to have sought medical, but not psychiatric, services in the prior year and faced significantly more cost barriers than participants without a mental disorder.

CONCLUSIONS

Findings suggest that Hispanic immigrants, particularly those with a mental illness, need to access services but face numerous systemic barriers. The authors recommend specific ways to make services more affordable and linguistically accessible.

Mental health service utilization for psychiatric disorders among Latinos living in the United States: the role of ethnic subgroup, ethnic identity, and language/social preferences

PURPOSE

To examine aspects of Latino experience in the US as predicting service utilization for mood, anxiety, and substance disorders.

METHODS

Latino participants 18 and older in the NESARC (N = 6,359), a US national face to face survey. Outcomes were lifetime service utilization for DSM-IV lifetime mood/anxiety or substance disorders, diagnosed via structured interview (AUDADIS-IV). Main predictors were ethnic subgroup, ethnic identity, linguistic/social preferences, nativity/years in the US, and age at immigration.

RESULTS

Higher levels of Latino ethnic identity and Spanish language/Latino social preferences predicted lower service utilization for mood disorders [ethnic identity OR = 0.52, language/social OR = 0.44] and anxiety disorders [ethnic identity OR = 0.67, language/social OR = 0.47], controlling for ethnic subgroup, disorder severity, time spent in the US, and economic and practical barriers Service utilization for alcohol/drug disorders was low across all Latino subgroups, without variation by examined predictors.

CONCLUSION

Ethnic/cultural factors are strong determinants of service utilization for mood/anxiety, but not substance use disorders among Latinos in the US strategies to increase service utilization among Latinos with psychiatric disorders should be disorder specific, and recognize the role of ethnicity and identity as important components of a help-seeking model.

Racial Disparities in Mental Health Outcomes After Psychiatric Hospital Discharge Among Individuals With Severe Mental Illness

Racial disparities in mental health outcomes have been widely documented in non-institutionalized community psychiatric samples, but few studies have specifically examined the effects of race among individuals with the most severe mental illnesses. A sample of 925 individuals hospitalized for severe mental illness were followed for a year after hospital discharge to examine the presence of disparities in mental health outcomes between African American and White individuals diagnosed with a severe psychiatric condition. Results from a series of individual growth curve models indicated that African American individuals with severe mental illness experienced significantly less improvement in global functioning, activation and anergia symptoms, and were less likely to return to work in the year following hospitalization. Racial disparities persisted after adjustment for sociodemographic and diagnostic confounders, and were largely consistent across gender, socioeconomic status, and psychiatric diagnosis. Implications for social work research and practice with minorities with severe mental illness are discussed.

Undiagnosed depression and its correlates in a predominantly immigrant Hispanic neurology clinic

OBJECTIVE

Previous studies have reported a high incidence of depression in neurology clinics, however areas where there are predominantly underserved immigrants have not been studied.

METHODS

Retrospective cohort study in an academic outpatient neurology clinic in Los Angeles, California. Newly referred patients (N=318) were assessed consecutively for depression using a PHQ-9 questionnaire, accompanied by review of the assessment of the depressive disorder.

RESULTS

The patient cohort consisted of 190 females (59%) and 130 males (41%), primarily of Hispanic descent (72%), with 8% Asian 11% white, and 5% African-American. Sixty-eight percent (68%) had depression, with 40% exhibiting moderate to severe depression. Patients who had moderate to severe depression (based on PHQ-9) were more likely to be unemployed (75.2% vs. 60.7%, p=0.008), dependent on government income (29.5% vs. 20.4%, p=0.06), and have headache or pain as the reason for referral (42.4% vs. 28.5%, p=0.03). Severity of depression also significantly correlated with current treatment by psychiatrist, current antidepressant use, and less independent living. Patients with moderate to severe depression were more likely to have made ER visits in the last 12 months (0.9 vs. 0.7, p=0.01) and were taking more medications (3.3 vs. 2.5, p=0.03), compared to patient with mild or no depression.

CONCLUSION

The presence of moderate to severe depression significantly correlated with socioeconomic status, use of emergency room, and presence of headache/pain. Neurology clinics with predominantly underserved immigrant patients have a disproportionate amount of depression, which may be related to socioeconomic factors resulting in overutilization of scarce healthcare resources.

Challenges to screening and evaluation of memory impairment among Hispanic elders in a primary care safety net facility

OBJECTIVE

Implement a memory impairment screening procedure for elderly Hispanic primary care patients, and analyze its yield and challenges to further triage and diagnostic evaluation.

METHODS

Three hundred twenty nine Hispanic patients aged ≥60 years or proxy informants were enrolled from outpatient primary care clinics at an urban safety-net medical center. Patients were screened for memory impairment using the WHO-UCLA AVLT; for those without consent capacity, proxies were given the IQCODE. Bilingual research assistants conducted in-person or telephone screening. Age, gender, education, comorbidities, acculturation, overall health, access to care, and memory concerns were assessed as potential predictors of memory impairment. Based on identified implementation challenges, a multi-disciplinary stakeholder committee proposed revised approaches to increase diagnostic evaluation and sustainability.

RESULTS

Of 677 eligible patients approached, 329 (49%) were screened, and 77 (23%) met criteria for memory impairment using the WHO-UCLA AVLT (N=60) or the IQCODE (N=17). Only male gender and higher comorbidity uniquely predicted memory impairment (ps<0.05). Few screen-positive patients declined further triage and evaluation, but a substantial proportion could not be subsequently contacted. Challenges to implementing a memory screening program included staff time and adequate clinic space for in-person screening; challenges to follow-up of positive screening results included inability to contact patients and lack of primary care continuity to facilitate further triage and referral.

CONCLUSIONS

Nearly one-fourth of primary care Hispanic elders screened as memory-impaired, but few factors predicted positive screening. Stakeholder-guided adaptations are needed-particularly in resource-constrained settings-to overcome challenges to further diagnostic evaluation and referral.

Help seeking and help receiving for emotional distress among Latino men and women

In this study, we examined help-seeking pathways and help-receiving experiences among Latinos, a population that has been shown to under-utilize mental health services. We used the qualitative approach of dual mode of analysis to explore the experiences of 13 Latino men and women who utilized formal as well as informal treatment and support resources. We explored three specific themes: (a) individual and family help-seeking perspectives intersecting with Latino cultural norms; (b) referral source and style, needs identification, and prior help-seeking experiences as key motivational factors for help seeking; and (c) client-therapist match and client-therapist relational style as integral to mental health treatment satisfaction. We discuss clinical implications for efforts to improve the cultural sensitivity and accessibility of mental health services.

Toward a technology of treatment individualization for young children with autism spectrum disorders

Although the etiology of autism spectrum disorders (ASD) and early development of the ASD are not yet well understood, recent research in the field of autism has heavily emphasized the importance of early intervention (i.e. treatment before the age of 4 years). Currently, several methods have been demonstrated to be efficacious with some children however no treatment completely ameliorates the symptoms of ASD or works for all children with the disorder. The heterogeneity and developmental nature of the disorder make it unlikely that one specific treatment will be best for all children, or will work for any one child throughout his or her educational career. Thus, this paper examines early research validating different technologies for individualizing treatment. A discussion of current research on pre-treatment characteristics associated with differential outcomes in treatment, including child, family, and practitioner variables; and how specific intervention techniques address each of those pre-treatment characteristics is provided. The ultimate goal of this line of research is to enable practitioners to prospectively tailor treatments to specific children and increase the overall rate of positives outcomes for children with autism. Research that furthers understanding of how to match clients with efficacious treatments will decrease the outcome variability that characterizes early intervention research at present, and provide for the most efficient allocation of resources during the critical early intervention time-period. This type of research is in its infancy, but is imperative if we are to determine a priori which treatment method will be most effective for a specific child.

Exploring the relationship between physical health, depressive symptoms, and depression diagnoses in Hispanic dementia caregivers

OBJECTIVES

The present study examined the relationship between self-reported physical health, depressive symptoms, and the occurrence of depression diagnosis in Hispanic female dementia caregivers.

PARTICIPANTS

Participants were 89 Hispanic female dementia caregivers.

DESIGN

This study used a cross-sectional design. Baseline depression and physical health data were collected from participants enrolled in the 'Reducing Stress in Hispanic Anglo Dementia Caregivers' study sponsored by the National Institute on Aging.

MEASUREMENTS

Physical health was assessed using the Medical Outcome Study Short Form-36 (SF-36), a one-item self-report health rating, body mass index, and the presence or history of self-reported physical illness. Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D). The occurrence of depression diagnosis was assessed using the Clinical Interview for DSM-IV Axis I Disorders (SCID).

ANALYSIS

Multiple linear and logistic regression analysis was used to examine the extent to which indices of physical health and depressive symptoms accounted for variance in participants' depressive symptoms and depressive diagnoses.

RESULTS

Self-reported indices of health (e.g., SF-36) accounted for a significant portion of variance in both CES-D scores and SCID diagnoses. Caregivers who reported worsened health tended to report increased symptoms of depression on the CES-D and increased likelihood of an SCID diagnosis of a depressive disorder.

CONCLUSION

Self-reported health indices are helpful in identifying Hispanic dementia caregivers at risk for clinical levels of depression.

Family intervention for co-occurring substance use and severe psychiatric disorders: participant characteristics and correlates of initial engagement and more extended exposure in a randomized controlled trial

Clients with severe mental illness and substance use disorder (i.e., dual disorders) frequently have contact with family members, who may provide valuable emotional and material support, but have limited skills and knowledge to promote recovery. Furthermore, high levels of family conflict and stress are related to higher rates of relapse. The present study was a two-site randomized controlled trial comparing a comprehensive, behaviorally-based family intervention for dual disorders program (FIDD) to a shorter-term family psychoeducational program (FPE). The modal family was a single male son in his early 30s diagnosed with both alcohol and drug problems and a schizophrenia-spectrum disorder participating with his middle-aged mother, with whom he lived. Initial engagement rates following consent to participate in the study and the family intervention programs were moderately high for both programs (88% and 84%, respectively), but rates of longer term retention and exposure to the core elements of each treatment model were lower (61% and 55%, respectively). Characteristics of the relatives were the strongest predictors of successful initial engagement in the family programs with the most important predictor being relatives who reported higher levels of benefit related to the relationship with the client. Subsequent successful exposure to the family treatment models was more strongly associated with client factors, including less severity of drug abuse and male client gender. The results suggest that attention to issues of motivating relatives to participate in family intervention, and more focused efforts to address the disruptive effects of drug abuse on the family could improve rates of engagement and retention in family programs for dual disorders.

Depression symptomatology and diagnosis: discordance between patients and physicians in primary care settings

Background

To examine the agreement between depression symptoms using an assessment tool (PHQ-9), and physician documentation of the same symptoms during a clinic visit, and then to examine how the presence of these symptoms affects depression diagnosis in primary care settings.

Methods

Interviewer administered surveys and medical record reviews. A total of 304 participants were recruited from 2321 participants screened for depression at two large urban primary care community settings.

Results

Of the 2321 participants screened for depression 304 were positive for depression and of these 75.3% (n = 229) were significantly depressed (PHQ-9 score ≥ 10). Of these, 31.0% were diagnosed by a physician with a depressive disorder. A total of 57.6% (n = 175) of study participants had both significant depression symptoms and functional impairment. Of these 37.7% were diagnosed by physicians as depressed. Cohen's Kappa analysis, used to determine the agreement between depression symptoms elicited using the PHQ-9 and physician documentation of these symptoms showed only slight agreement (0.001–0.101) for all depression symptoms using standard agreement rating scales. Further analysis showed that only suicidal ideation and hypersomnia or insomnia were associated with an increased likelihood of physician depression diagnosis (OR 5.41 P sig < .01 and (OR 2.02 P sig < .05 respectively). Other depression symptoms and chronic medical conditions had no affect on physician depression diagnosis.

Conclusion

Two-thirds of individuals with depression are undiagnosed in primary care settings. While functional impairment increases the rate of physician diagnosis of depression, the agreement between a structured assessment and physician elicited and or documented symptoms during a clinical encounter is very low. Suicidality, hypersomnia and insomnia are associated with an increase in the rate of depression diagnosis even when physician and self report of the symptom differ. Interventions that emphasize the use of routine structured screening of primary care patients might also improve the rate of diagnosis of depression in these settings. Further studies are needed to explore depression symptom assessment during physician patient encounter in primary care settings.

Integrated primary care and behavioral health services for Latinos: a blueprint and research agenda

Disparities in Latino utilization of mental health services have been documented for some years. Factors such as stigma, low rates of health insurance, paucity of culturally competent providers, and linguistic inaccessibility have contributed to this underutilization. The documented tendency of many Latinos to experience the mind and body as a unified whole, often referred to as "non-dualism"; provides a unique opportunity to address these disparities in utilization. This article advocates a specific model of engagement of Latinos into a continuum of needed behavioral health services via the primary care clinic, and suggests a variety of clinical and administrative outcome measures for evaluating the effectiveness of the model. The model centers on the inclusion of a behavioral health specialist who is "nested" within the primary care team. The preparation and perspectives of clinically trained social workers make them ideal for this role.

National trends in ethnic disparities in mental health care

OBJECTIVE

To compare trends in office-based treatment of mental disorders between Hispanics and non-Hispanics.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of a nationally representative sample of visits to office-based physicians conducted between 1993 and 2002 (N = 251,905). Visits were grouped into 3 discrete time periods, 1993-1996, 1997-1999 and 2000-2002.

MAIN OUTCOME MEASURES

Rate of diagnosis, type of mental health visit, type of treatment received (medication or psychotherapy), rate of psychotropic medications prescription, and specialty of the treating physician.

RESULTS

From 1993-1996 to 2000-2002, the proportion of office visits in which mental health care was provided decreased for Hispanics from 12.2% to 11.7% while it increased from 13.1% to 15.7% for non-Hispanics (P < 0.05). Visits with a diagnosis of mental disorder decreased from 5.2% to 5.1% in Hispanics but increased from 6.0% to 8.8% in non-Hispanics (P < 0.05). Visits resulting in prescription of a psychotropic medication decreased from 10.2% to 9.3% in Hispanics, while they increased from 10.2% to 12.5% in non-Hispanics (P < 0.05). Psychotherapy visits decreased from 2.4% to 1.3% in Hispanics (P < 0.05), whereas they remained constant (2.5%) in non-Hispanics. Visits to a psychiatrist decreased from 2.5% to 1.3% in Hispanics (P < 0.05), while they increased (nonsignificantly) from 3.1% to 3.5% for non-Hispanics. Most differences persisted after adjusting for age and insurance status.

CONCLUSIONS

From 1993 to 2002, there was an increase in mental health care disparities between Hispanics and non-Hispanics treated by office-based physicians. Improvement of the mental health care for Hispanics continues to be an important public health priority, with clear opportunities and challenges for health care policy-makers and practitioners.

Health service utilization by Ethiopian immigrants and refugees in Toronto

The purpose of this study was to examine the health service utilization patterns of Ethiopian immigrants and refugees in a random sample of 342 adults residing in Toronto. The results suggested that 85% of the study participants used one or more type of health services, most often from a family physician. However, only 12.5% of them with a mental disorder received services from formal healthcare providers, mainly family physicians. While the presence of somatic symptoms was significantly associated with increased use of healthcare (p < 0.05), having a mental disorder was associated with lower rate of health service use (p < 0.05). These findings suggest that family physicians could play important role in identifying and treating Ethiopian clients who present with somatic symptoms, as these symptoms may reflect mental health problems. Further research is necessary to determine the reasons for the low rates of mental health services use in this population.

Discontinuation of antidepressant medication among Latinos in the USA

Despite recent growth in the variety of antidepressant medications available, many patients discontinue medication prematurely for reasons such as nonresponse, side effects, stigma, and miscommunication. Some analysts have suggested that Latinos may have higher antidepressant discontinuation rates than other US residents. This paper examines Latino antidepressant discontinuation, using data from a national probability survey of Latinos in the USA. In this sample, 8% of Latinos had taken an antidepressant in the preceding 12 months. Among those users, 33.3% had discontinued taking antidepressants at the time of interview, and 18.9% had done so without prior input from their physician. Even controlling for clinical and other variables, patients who reported good or excellent English proficiency were less likely to stop at all. Patients were also less likely to stop if they were older, married, had public or private insurance, or had made eight or more visits to a nonmedical therapist.

Latino immigrants' intentions to seek depression care

This study examined the role that illness perceptions, attitudes toward depression treatments, and subjective norms played in Latino immigrants' intentions to seek depression care. Ninety-five Latino immigrant patients were presented a vignette depicting an individual with major depression and interviewed about their intentions to seek care if confronted with a similar situation. Patients' preferences were to rely on informal sources of care first, and then turn to formal sources to cope with depression. Findings showed Latinos immigrants' help-seeking intentions for depression were a function of their views of depression, attitudes toward their doctors' interpersonal skills, and social norms related to seeking professional care after controlling for demographics, health insurance status, acculturation, clinical characteristics, perceived barriers to care, and past service use.

Correlates of past-year mental health service use among Latinos: results from the National Latino and Asian American Study

OBJECTIVES

We examined correlates and rates of past-year mental health service use in a national sample of Latinos residing in the United States.

METHODS

We used data from the National Latino and Asian American Study, a national epidemiological household survey of Latinos.

RESULTS

Cultural factors such as nativity, language, age at migration, years of residence in the United States, and generational status were associated with whether or not Latinos had used mental health services. However, when the analysis was stratified according to past-year psychiatric diagnoses, these associations held only among those who did not fulfill criteria for any of the psychiatric disorders assessed. Rates of mental health service use among those who did not fulfill diagnostic criteria were higher among Puerto Ricans and US-born Latinos than among non-Puerto Ricans and foreign-born Latinos.

CONCLUSIONS

Rates of mental health service use among Latinos appear to have increased substantially over the past decade relative to rates reported in the 1990s. Cultural and immigration characteristics should be considered in matching mental health services to Latinos who need preventive services or who are symptomatic but do not fulfill psychiatric disorder criteria.

“It’s Like Going through an Earthquake”: Anthropological Perspectives on Depression among Latino Immigrants

Depression is one of the most prevalent mental illnesses in the community and is responsible for a significant amount of disability. According to epidemiological and primary care studies, Latinos suffer from depression at high rates. This paper examines in depth Latinos' conceptions of depression and their attitudes towards and expectations of mental health treatment. The aim of this paper is to summarize several qualitative studies examining Latinos' cultural understandings of mental health in general and depression in particular, as well as to obtain information about the barriers to care that this community experienced. The results are a compilation of findings from four different research projects in New Jersey and New York that examined diverse Latinos' conceptions of mental health, treatment and barriers to care.

Latino adults' access to mental health care: a review of epidemiological studies

Since the early 1980s, epidemiological studies using state-of-the-art methodologies have documented the unmet mental health needs of Latinos adults in the U.S. and Puerto Rico. This paper reviews 16 articles based on seven epidemiological studies, examines studies methodologies, and summarizes findings about how Latino adults access mental health services. Studies consistently report that, compared to non-Latino Whites, Latinos underutilize mental health services, are less likely to receive guideline congruent care, and rely more often on primary care for services. Structural, economic, psychiatric, and cultural factors influence Latinos' service access. In spite of the valuable information these studies provide, methodological limitations (e.g., reliance on cross-sectional designs, scarcity of mixed Latino group samples) constrict knowledge about Latinos access to mental health services. Areas for future research and development needed to improve Latinos' access and quality of mental health care are discussed.

Recent treatment history vs clinical characteristics in the prediction of use of outpatient psychiatric services

BACKGROUND

The use of outpatient psychiatric services has been shown to be a complex function of sociodemographic, clinical, and pathway variables. The relative contribution of each variable or groups of variables in explaining the variability in the use of outpatient psychiatric services, however, remains poorly documented.

METHODS

The subjects (N=382) were all patients admitted to an outpatient psychiatric clinic serving mostly a minority and low-income population. The charts of the patients were reviewed for sociodemographic, clinical, and pathway variables and the number of outpatient visits. The pathway variables studied were source of referral and most recent psychiatric treatment service used. Both bivariate and multivariate statistics were used to analyze the data.

RESULTS

Pathway variables were better predictors of the number of outpatient visits than clinical variables after controlling for sociodemographic variables.

CONCLUSION

Patients recently hospitalized may be sicker or have fewer social supports and therefore require more outpatient visits. Recent treatment history stands out as an important variable in the prediction of the number of outpatient mental health visits. More research is needed to examine the influence of pathway variables on treatment decisions.

Help seeking for mental health problems among Mexican Americans

This study uses data from a household survey (Mexican American Prevalence and Services Study; MAPSS) of 3,000 respondents in Fresno County, California, to 1) contrast use across multiple sectors of care among immigrant and U.S. born Mexican Americans with recent psychiatric disorders, 2) contrast multiple provider utilization patterns, and 3) identify specific factors associated with the use of mental health specialty and general medical sectors. Immigrants and U.S. born disproportionately used the general medical sector for treating mental health problems. The U.S. born were more likely to use family physicians and counselors than were immigrants, and neither relied heavily upon informal network providers to treat psychiatric disorders. A comparison of patterns showed that most people with a recent disorder used a combination of providers. The logistic regression analyses showed that knowing where to find a provider increased the likelihood of specialty mental health use by an odds ratio (O.R.) of 4.68. Private insurance increased use of mental health providers, O.R. = 3.76. Public insurance availability did not increase mental health provider use, suggesting that other factors were linked to use of mental health specialty care. Public insurance did increase medical sector care for psychiatric problems, O.R. = 2.57. Poor self-rated mental health status was primarily associated with use of physicians by U.S. born (O.R. = 5.39). Severe mental health impairment increased use of both general medical (O.R. = 5.54) and specialty mental health (O.R. = 5.1) providers. These results point out that eligibility for public insurance is a necessary but not sufficient status to increase mental health sector care among immigrants, and education and more effective referral from other sectors are needed to encourage use of these services.

Immigration reform and the health of Latino immigrants in California

This paper examines Latino immigrant health within the context of the current debate over immigration reform and the resulting cultural construction of public health in California. A review of epidemiologic and ethnographic data indicates that the subordinate socioeconomic status of Latino immigrants plays a major role in both disease etiology and access to health services. However, this status does not explain why certain patterns of health services utilization and disease morbidity and mortality persist although political and economic circumstances have changed. These patterns include the reluctance to utilize certain health services despite access to health insurance and the presence of an epidemiologic paradox in which Latinos have health status indicators comparable to or better than that of other ethnic groups despite high poverty, low education, and lack of access to care. An "economy of culture" model is used to explain these inconsistencies in the political economy model of Latino immigrant health.

Mental health needs and treatment of foster youth: barriers and opportunities

This article reviews current research on emotional and behavioral disorders among children in foster care and summarizes findings regarding utilization of mental health services in this population. Barriers to needed care are explored, practice and policy implications of lack of care are discussed, and alternative, evidence-based treatment options for foster youth are examined and proposed.

Social and behavioral correlates of cigarette smoking among mid-Atlantic Latino primary care patients

Tobacco use is the leading preventable cause of death for the U.S. Hispanic population. The goal of this study was to identify social and behavioral correlates of smoking behavior among urban, multiethnic Latino primary care patients seen in community clinics. Spanish-language interviews were completed with 141 current smokers and 158 former and nonsmokers. Twenty countries of origin were represented. Eighty-three percent of participants were from Central or South America and 71% spoke primarily Spanish. Current smokers were more likely than nonsmokers or former smokers to originate from South America (38% versus 26%) and to be single (63% versus 42%). Current smokers also were more likely to use alcohol on a regular basis (59% versus 31%) and to experience daily symptoms of depression (29% versus 19%). Logistic regression analysis suggested a moderating effect of depression on the relationship between alcohol use and smoking, such that current users of alcohol who reported depression were more likely to smoke (82%) than were current users of alcohol who did not report depression (56%). As both social and behavioral factors were uniquely associated with smoking, country of origin, marital status, and comorbid alcohol use and depression should be considered in designing and implementing tobacco control interventions targeted to this community.

Effects of culturally adapted parent management training on Latino youth behavioral health outcomes

A randomized experimental test of the implementation feasibility and the efficacy of a culturally adapted Parent Management Training intervention was conducted with a sample of 73 Spanish-speaking Latino parents with middle-school-aged youth at risk for problem behaviors. Intervention feasibility was evaluated through weekly parent satisfaction ratings, intervention participation and attendance, and overall program satisfaction. Intervention effects were evaluated by examining changes in parenting and youth adjustment for the intervention and control groups between baseline and intervention termination approximately 5 months later. Findings provided strong evidence for the feasibility of delivering the intervention in a larger community context. The intervention produced benefits in both parenting outcomes (i.e., general parenting, skill encouragement, overall effective parenting) and youth outcomes (i.e., aggression, externalizing, likelihood of smoking and use of alcohol, marijuana, and other drugs). Differential effects of the intervention were based on youth nativity status.