Does Medicare Managed Care Provide Equal Treatment for Mental IllnessAcross Races?

Healthcare utilization among patients with psychiatric hospitalization admitted through the emergency department (ED): A claims-based study

OBJECTIVE

To characterize the US national level healthcare utilization patterns of patients with commercial insurance plans before and after a psychiatric hospitalization admitted through the emergency department (ED) using insurance claims data.

METHOD

We identified 34,250 patients from multiple commercial health insurance providers across the US who meet our eligibility criteria. We summarized their healthcare encounters and used logistic regression models to study the patterns of healthcare utilization including prior visits, outpatient follow-ups, and hospital- or ED-readmissions.

RESULTS

Suicidal ideation was highly prevalent at the time of the index event (29.88%). Almost half of the patients (48.28%) had healthcare encounters with the same primary diagnosis one year before admission, about 5% had outpatient follow-ups or were readmitted to the hospital or ED 7 days post discharge. The post 30-day follow-ups and readmission rates were slightly higher. In general, older patients were less likely to have prior visits, follow-ups, or readmissions, and patients with SUDs, specifically alcohol dependence, opioid dependence/abuse, and stimulant dependence, were more likely to have outpatient follow-ups.

CONCLUSION

Patterns of patients' prior visits, follow-ups, and readmissions varied by demographics and psychiatric comorbidity. Additional studies are needed to further explain the spatial variations of utilization patterns.

Treatment Initiation for New Episodes of Depression in Primary Care Settings

BACKGROUND

Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment.

OBJECTIVE

To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings.

DESIGN

A retrospective observational design was used to analyze electronic health record data.

PATIENTS

A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013.

MAIN MEASURES

ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis.

KEY RESULTS

Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged  ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication.

CONCLUSIONS

Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.

Ethnic minority inequalities in access to treatments for schizophrenia and schizoaffective disorders: findings from a nationally representative cross-sectional study

BACKGROUND

Ethnic minority service users with schizophrenia and schizoaffective disorders may experience inequalities in care. There have been no recent studies assessing access to evidence-based treatments for psychosis amongst the main ethnic minority groups in the UK.

METHODS

Data from nationally representative surveys from England and Wales, for 10,512 people with a clinical diagnosis of schizophrenia or schizoaffective disorders, were used for analyses. Multi-level multivariable logistic regression analyses were used to assess ethnic minority inequalities in access to pharmacological treatments, psychological interventions, shared decision making and care planning, taking into account a range of potential confounders.

RESULTS

Compared with white service users, black service users were more likely prescribed depot/injectable antipsychotics (odds ratio 1.56 (95% confidence interval 1.33-1.84)). Black service users with treatment resistance were less likely to be prescribed clozapine (odds ratio 0.56 (95% confidence interval 0.39-0.79)). All ethnic minority service users, except those of mixed ethnicity, were less likely to be offered cognitive behavioural therapy, compared to white service users. Black service users were less likely to have been offered family therapy, and Asian service users were less likely to have received copies of care plans (odds ratio 0.50 (95% confidence interval 0.33-0.76)), compared to white service users. There were no clinician-reported differences in shared decision making across each of the ethnic minority groups.

CONCLUSION

Relative to white service users, ethnic minority service users with psychosis were generally less likely to be offered a range of evidence-based treatments for psychosis, which included pharmacological and psychological interventions as well as involvement in care planning.

Improving the health of African Americans in the USA: an overdue opportunity for social justice

Using a modified social ecological model, we conducted a review of the literature and nationwide statistics on African American health. We discuss the main social determinants of health and main health disparities, risk factors, the leading causes of morbidity and mortality, and access to health services for blacks in the USA. The mechanisms through which social determinants, including racism, exert their deleterious effects on black health are discussed at the macro and individual levels. Incarceration and mental health care issues are highlighted as priorities to be addressed. African Americans remain the least healthy ethnic group in the USA, a somber legacy of years of racial and social injustice and a formidable challenge to equitable health care for all. Systemic causes of suboptimal black health require equally systemic solutions; positive trends in black health indicators seem to be driven by social development programs, economic investment in education, participation of African Americans in policy, and decision-making and expansion of access to health care.

Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network

OBJECTIVE

The objective of this study was to characterize racial-ethnic variation in diagnoses and treatment of mental disorders in large not-for-profit health care systems.

METHODS

Participating systems were 11 private, not-for-profit health care organizations constituting the Mental Health Research Network, with a combined 7,523,956 patients age 18 or older who received care during 2011. Rates of diagnoses, prescription of psychotropic medications, and total formal psychotherapy sessions received were obtained from insurance claims and electronic medical record databases across all health care settings.

RESULTS

Of the 7.5 million patients in the study, 1.2 million (15.6%) received a psychiatric diagnosis in 2011. This varied significantly by race-ethnicity, with Native American/Alaskan Native patients having the highest rates of any diagnosis (20.6%) and Asians having the lowest rates (7.5%). Among patients with a psychiatric diagnosis, 73% (N=850,585) received a psychotropic medication. Non-Hispanic white patients were significantly more likely (77.8%) than other racial-ethnic groups (odds ratio [OR] range .48-.81) to receive medication. In contrast, only 34% of patients with a psychiatric diagnosis (N=548,837) received formal psychotherapy. Racial-ethnic differences were most pronounced for depression and schizophrenia; compared with whites, non-Hispanic blacks were more likely to receive formal psychotherapy for their depression (OR=1.20) or for their schizophrenia (OR=2.64).

CONCLUSIONS

There were significant racial-ethnic differences in diagnosis and treatment of psychiatric conditions across 11 U.S. health care systems. Further study is needed to understand underlying causes of these observed differences and whether processes and outcomes of care are equitable across these diverse patient populations.

Depression Remission Rates Among Older Black and White Adults: Analyses From the IRL-GREY Trial

OBJECTIVE

This study explored whether older black and white adults with major depressive disorder differed in rates of remission or attrition during open-label treatment with venlafaxine and supportive care.

METHODS

A total of 47 black (10%) and 412 white (90%) adults age ≥60 were treated with open-label venlafaxine extended-release (≤300 mg per day) for 12-14 weeks during the initial phase of an multisite, randomized, placebo-controlled augmentation trial. Participants were help-seeking older adults with nonpsychotic major depressive disorder (single or recurrent episode) referred from specialty clinics, primary care practices, advertisements, and research programs. Remission was defined as a Montgomery-Asberg Depression Rating Scale score of ≤10 for two consecutive assessments at the end of 12 weeks. Kaplan-Meier curves displayed time to dropout and time to initial remission. Cox proportional hazards models assessed differences in attrition and remission rates.

RESULTS

Black participants had greater baseline general medical comorbidity, worse physical health-related quality of life, and poorer cognitive function than white participants. White participants were more likely to have received an adequate trial of antidepressant and psychotherapy before study entry. Baseline depression severity, depression duration, age at onset, and recurrence history did not differ between groups. The groups had similar final doses of venlafaxine and similar rates of attrition and remission. Side-effect profiles were comparable between the groups.

CONCLUSIONS

Despite greater medical comorbidity, lower cognitive function, and less adequate prior exposure to antidepressant treatment and psychotherapy, black participants were no more likely to discontinue antidepressant pharmacotherapy and experienced a rate of remission comparable to white participants.

Illness beliefs of Chinese American immigrants with major depressive disorder in a primary care setting

Underutilization of mental health services in the U.S. is compounded among racial/ethnic minorities, especially Chinese Americans. Culturally based illness beliefs influence help-seeking behavior and may provide insights into strategies for increasing utilization rates among vulnerable populations. This is the first large descriptive study of depressed Chinese American immigrant patients' illness beliefs using a standardized instrument. 190 depressed Chinese immigrants seeking primary care at South Cove Community Health Center completed the Explanatory Model Interview Catalogue, which probes different dimensions of illness beliefs: chief complaint, labeling of illness, stigma perception, causal attributions, and help-seeking patterns. Responses were sorted into categories by independent raters and results compared to an earlier study at the same site and using the same instrument. Contrary to prior findings that depressed Chinese individuals tend to present with primarily somatic symptoms, subjects were more likely to report chief complaints and illness labels related to depressed mood than physical symptoms. Nearly half reported they would conceal the name of their problem from others. Mean stigma levels were significantly higher than in the previous study. Most subjects identified psychological stress as the most likely cause of their problem. Chinese immigrants' illness beliefs were notable for psychological explanations regarding their symptoms, possibly reflecting increased acceptance of Western biomedical frameworks, in accordance with recent research. However, reported stigma regarding these symptoms also increased. As Asian American immigrant populations increasingly accept psychological models of depression, stigma may become an increasingly important target for addressing disparities in mental health service utilization.

Quality of follow-up after hospitalization for mental illness among patients from racial-ethnic minority groups

OBJECTIVE

Outpatient follow-up after hospitalization for mental health reasons is an important indicator of quality of health systems. Differences among racial-ethnic minority groups in the quality of service use during this period are understudied. This study assessed the quality of outpatient treatment episodes following inpatient psychiatric treatment among blacks, whites, and Latinos in the United States.

METHODS

The Medical Expenditure Panel Survey (2004-2010) was used to identify adults with any inpatient psychiatric treatment (N=339). Logistic regression models were used to estimate predictors of any outpatient follow-up or the beginning of adequate outpatient follow-up within seven or 30 days following discharge. Predicted disparities were calculated after adjustment for clinical need variables but not for socioeconomic characteristics, consistent with the Institute of Medicine definition of health care disparities as differences that are unrelated to clinical appropriateness, need, or patient preference.

RESULTS

Rates of follow-up were generally low, particularly rates of adequate treatment (<26%). Outpatient treatment prior to inpatient care was a strong predictor of all measures of follow-up. After adjustment for need and socioeconomic status, the analyses showed that blacks were less likely than whites to receive any treatment or begin adequate follow-up within 30 days of discharge.

CONCLUSIONS

Poor integration of follow-up treatment in the continuum of psychiatric care leaves many individuals, particularly blacks, with poor-quality treatment. Culturally appropriate interventions that link individuals in inpatient settings to outpatient follow-up are needed to reduce racial-ethnic disparities in outpatient mental health treatment following acute treatment.

Antidepressant utilization after hospitalization with depression: a comparison between non-Western immigrants and Danish-born residents

BACKGROUND

Antidepressant (AD) therapy is recommended for patients 4-12 months after remission from depression. The aim was to examine whether immigrants (refugees or family reunited immigrants) from non-Western countries are at greater risk than Danish-born residents of 1) not initiating AD therapy after discharge and 2) early AD discontinuation.

METHODS

A cohort of immigrants from non-Western countries (n = 132) and matched Danish-born residents (n = 396) discharged after first admission with moderate to severe depression between 1 January 1996 and 31 May 2008 was followed in the Danish registries.Logistic regression models were applied to explore AD initiation within 30 days after discharge, estimating odds ratio (OR) for immigrants versus Danish-born residents.Early discontinuation was explored by logistic regression, estimating OR for no AD dispensing within 180 days after the first dispensing, and by Cox regression, estimating hazard ratio (HR) for discontinuation (maximum drug supply gap) within 180 days.

RESULTS

Immigrants had higher odds for not initiating AD treatment after discharge than Danish-born residents (OR = 1.55; 95% CI: 1.01-2.38). When income was included in the model, the strength of the association was attenuated. Odds for early discontinuation was non-significantly higher among immigrants than Danish-born residents (OR = 1.80; 0.87-3.73). Immigrants also had a non-significantly higher hazard of early discontinuation (HR = 1.46; 95% CI: 0.87-2.45). Including income had only minor impact on these associations.

CONCLUSION

Immigrants seem less likely to receive the recommended AD treatment after hospitalization with depression. This may indicate a need for a better understanding of the circumstances of this vulnerable group.

Assessing racial/ethnic disparities in treatment across episodes of mental health care

OBJECTIVE

To investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment.

STUDY DESIGN

We analyzed whites, blacks, and Latinos with probable mental illness from Panels 9-13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination).

FINDINGS

Compared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care.

CONCLUSIONS

Disparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks' higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks' greater acute mental health care use raises concerns over monitoring of their treatment.

Mental health resource utilization and health care costs associated with race and comorbid anxiety among Medicaid enrollees with major depressive disorder

OBJECTIVE

The objective of this study was to assess the association among race, comorbid anxiety, and mental health resource utilization among Medicaid enrollees with major depressive disorder (MDD).

METHODS

A retrospective cross-sectional study design was used to identify adult patients with MDD newly initiating an antidepressant between January 1, 2004, and December 31, 2006, from the MarketScan Multi-State Medicaid Database. Measures of mental health resource utilization included mental health-related office visits, hospitalizations, emergency department visits, and health care costs. The associations of mental health resource utilization with race and comorbid anxiety were examined respectively using multivariable logistic regression, negative binominal regression, and log-transformed linear regression models.

RESULTS

A total of 3083 Medicaid enrollees with MDD were included. Approximately 25% of patients had comorbid anxiety. Caucasians were more likely to have comorbid anxiety than African Americans (30.2% vs 16.4%, p < .01). After controlling for covariates, comorbid anxiety was significantly associated with more frequent mental health resource utilization. African Americans were significantly less likely than Caucasians to have mental health-related office visits (OR, 0.54; 95% CI, 0.45-0.66) but more likely to be hospitalized (OR, 2.57; 95% CI, 1.84-3.60) and to have emergency department visits (OR, 1.52; 95% CI, 1.05-2.19).

CONCLUSIONS

Comorbid anxiety was positively associated with mental health resource utilization among Medicaid enrollees with MDD. Health disparities in health care utilization between African Americans and Caucasians still exist.

The validity of race and ethnicity in enrollment data for Medicare beneficiaries

OBJECTIVE

To assess the validity of race/ethnicity in Medicare databases for studies of racial/ethnic disparities.

DATA SOURCES

The 2010 Medicare Consumer Assessments of Healthcare Providers and Systems (CAHPS(®)) survey was linked to Medicare enrollment data and local area characteristics from the 2000 Census.

STUDY DESIGN

Race/ethnicity was cross-tabulated for CAHPS and Medicare data. Within each self-reported category, demographic, geographic, health, and health care variables were compared between those that were and were not similarly identified in Medicare data.

DATA COLLECTION METHODS

The Medicare CAHPS survey included 343,658 responses from elderly participants (60 percent response rate). Data were weighted for sampling and nonresponse to be representative of the national population of elderly Medicare beneficiaries.

PRINCIPAL FINDINGS

Self-reported Hispanics, Asians, Pacific Islanders, and American Indians were underidentified in Medicare enrollment data. Individuals in these groups who were identified in Medicare data tended to be more strongly identified with their group, poorer, and in worse health and to report worse health care experiences than those who were not so identified.

CONCLUSIONS

Self-reported members of racial and ethnic groups other than Whites and Blacks who are identified in Medicare data differ substantially from those who are not so identified. These differences should be considered in assessments of disparities in health and health care among Medicare beneficiaries.

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.

Variation in diabetes care quality among medicare advantage plans: understanding the role of case mix

This study investigates whether variation in Medicare Advantage plan performance on comprehensive diabetes care is explained by the case mix of plans. Using data on 513 Medicare Advantage plan-year observations for 2007 and 2008, the authors estimate multivariate regressions for 3 diabetes care quality measures: (1) hemoglobin screening, (2) low-density lipoprotein screening, and (3) retinal eye exam. Plan case mix is measured with the percentage of a plan's enrollees who have type 1 diabetes with and without comorbidities and the percentage of a plan's enrollees who have type 2 diabetes with and without comorbidities. Plans with a higher percentage of enrollees with type 1 diabetes with comorbidity and plans with a higher percentage of enrollees with type 2 diabetes without comorbidity have lower performance, on average. Finding evidence of a relationship between case mix and Healthcare Effectiveness Data and Information Set performance reinforces the argument for developing standardized risk adjustment or stratification methods in public reporting and pay-for-performance efforts.

Shared conceptualizations and divergent experiences of counseling among African American and white older adults

Research findings suggest that older adults prefer counseling for depression treatment; however, few older adults use counseling services. In this article we present the results of our analysis of semistructured interviews with 102 older adults to explore conceptualizations of counseling and impediments to use among African American and White older adults. We found that older adults believe counseling is beneficial; however, use was hindered in multiple ways. Older adults were skeptical about establishing a caring relationship with a professional. African American older adults did not mention social relationships to facilitate depression care, whereas White older adults described using personal relationships to navigate counseling services. African American older men were least familiar with counseling. Our findings suggest that African American and White older adults share a strong cultural model of counseling as beneficial; however, significant impediments exist and affect older adults differentially based on ethnicity.

Effect of copayments on use of outpatient mental health services among elderly managed care enrollees

BACKGROUND

Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations.

OBJECTIVE

To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly.

RESEARCH DESIGN

Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments.

STUDY POPULATION

A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥ 25%, 3 plans that decreased copayments by ≥ 25%, and 17 matched control plans with unchanged copayments.

RESULTS

In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0-0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, -0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results.

CONCLUSIONS

Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.

Ethnic differences in antidepressant response: a prospective multi-site clinical trial

BACKGROUND

Although depression is a highly prevalent condition that occurs in all ethnic groups, the influence of ethnicity on treatment response still remains unclear.

METHODS

A prospective 8-week, open-label clinical trial comparing the efficacy and side effects of citalopram (CIT) with dose escalation (20-60 mg/day) was performed in African-Americans and Caucasians with nonpsychotic major depression. The intent-to-treat sample consisted of 301 participants (169 African-Americans and 132 Caucasians).

RESULTS

Although African-Americans were more socially disadvantaged and had a more severe depression, outcomes between the groups were similar. Remission rates were approximately 50% in both groups and about 2/3 of participants met response criteria. Retention was greater than 75% in both groups, with no differences in dropout rate. There were no differences in the number of completers, number of visits made, final dose of CIT, or in side effect profiles.

CONCLUSIONS

These results confirm the growing body of evidence, including recent studies using measurement-based care, that patients from minority groups have outcomes that are similar to those of Caucasians. The provision of measurement-based care and encouragement of patient participation can reduce ethnic differences in response to treatment for depression.

Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan

OBJECTIVE

This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities.

METHODS

Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.

RESULTS

Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.

CONCLUSIONS

Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.

Longitudinal racial/ethnic disparities in antimanic medication use in bipolar-I disorder

OBJECTIVE

To examine racial/ethnic longitudinal disparities in antimanic medication use among adults with bipolar-I disorder.

METHODS

Observational study using administrative data from Florida's Medicaid program, July 1997 to June 2005, for enrollees diagnosed with bipolar-I disorder (N = 13,497 persons; 126,413 person-quarters). We examined the likelihood of receiving one of the following during a given quarter: (1) any antimanic agent (antipsychotic or mood stabilizer) or none, and (2) mood stabilizers, antipsychotic monotherapy, or neither. Binary and multinomial logistic regression models predicted the association between race/ethnicity and prescription fills, adjusting for clinical and demographic characteristics. Cohort indicators for year that the enrollee met study criteria were included to account for cohort effects.

RESULTS

Averaging over all cohorts and quarters, compared with whites, blacks had lower odds of filling any antimanic and mood stabilizer prescriptions specifically (40%-49% and 47%-63%, respectively), but similar odds of filling prescriptions for antipsychotic monotherapy. After Bonferroni adjustment, compared with whites, there were no statistically significant disparities for Hispanics in filling prescriptions for any, or specific antimanic medications.

CONCLUSIONS

Rates of antimanic medication use were low regardless of race/ethnicity. However, we found disparities in antimanic medication use for blacks compared with whites and these disparities persisted over time. We found no Hispanic-white disparities. Quality improvement efforts should focus on all individuals with bipolar disorder, but particular attention should be paid to understanding disparities in medication use for blacks.

Reducing psychosocial and behavioral pregnancy risk factors: results of a randomized clinical trial among high-risk pregnant african american women

OBJECTIVES

We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence).

METHODS

Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up.

RESULTS

Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021).

CONCLUSIONS

In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review

OBJECTIVE

Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.

METHODS

MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.

RESULTS

In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.

CONCLUSIONS

Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

Unmet needs for mental health services for latino older adults: perspectives from consumers, family members, advocates, and service providers

This study qualitatively assessed the need for mental health services among Latino older adults in San Diego, California. The primary mental health issue was depression. Primary organizational barriers to accessing services were language and cultural barriers secondary to a lack of translators, dearth of information on available services, and scarcity of providers representative of the Latino community. Other challenges included a lack of transportation and housing, and the need for socialization and social support. Latino older adults experienced their unmet needs in ways associated with their cultural background and minority status. Age- and culturally-appropriate services are needed to overcome these barriers.

Ethnicity/race and outcome in the treatment of depression: results from STAR*D

OBJECTIVES

This secondary analysis of data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study compared rates of remission and response for blacks (n = 495), whites (n = 1853), and Hispanics (n = 327) with nonpsychotic major depressive disorder who were treated with citalopram.

METHODS

STAR*D included representative outpatients treated in 23 psychiatric and 18 primary care centers. Participants received flexible doses of citalopram for up to 14 weeks, with dosage adjustments based on routine clinical assessments. Efforts were made to achieve remission, using a measurement-based care approach with adjustments based on symptoms and side effects assessed at each visit.

RESULTS

There were significant differences among groups on many baseline demographic, sociocultural, and clinical variables. Blacks and Hispanics were more socially disadvantaged and had more comorbidity than whites. Before adjusting for differences, blacks had lower remission rates than whites, with Hispanics intermediate between the 2. After adjustments, remission rates for groups were not significantly different on the 17-item Hamilton Rating Scale for Depression (HRSD), but remained lower for blacks compared with whites with the 16-item Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR). Blacks took longer to achieve remission or response, though this did not remain after adjusting for baseline differences.

CONCLUSIONS

Overall, black and to a lesser extent Hispanic participants had a poorer response to citalopram. After adjusting for baseline differences, the remission rates seemed to be more similar on the HRSD, but remained worse for blacks on the QIDS-SR. We discuss the possible biologic and sociocultural factors that may underlie these findings.

The effects of health sector market factors and vulnerable group membership on access to alcohol, drug, and mental health care

OBJECTIVE

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.

DATA SOURCES

Wave 2 data (2000-2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997-1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.

STUDY DESIGN

The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.

PRINCIPAL FINDINGS

Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use. For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration. However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.

CONCLUSIONS

Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage. Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities. More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.

Are there racial differences in the experience of harmful or traumatic events within psychiatric settings?

The current study examined racial differences in the reported frequency and distress associated with potentially harmful or traumatic experiences occurring within psychiatric settings. One hundred and forty-two (109 African-American; 32 Caucasian) randomly selected adult consumers recruited from a community psychosocial day program completed a battery of self-report measures to assess experiences in the psychiatric setting, lifetime trauma exposure, PTSD severity, and were the subject of a chart review. A subset of participants (20%) also completed a qualitative interview exploring their perceptions of events occurring in psychiatric settings. Few racial differences were noted in the reported frequency or distress associated with particular events in the psychiatric setting. However, we found differential patterns of association between adverse psychiatric events and lifetime trauma history, and racial differences in diagnosis and medications prescribed by the mental health center. These racial differences merit further attention to better understand their meaning and to improve mental health services provided to both African-Americans and Caucasian public-sector psychiatric patients.

Ethnicity and preferences for depression treatment

OBJECTIVE

The objective of this work was to describe ethnic differences in attitudes toward depression, depression treatment, stigma and preferences for depression treatment (counseling vs. medication).

METHOD

This study used a cross-sectional Internet survey measuring treatment preference, stigma and attitudes toward depression. Depressive symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale. Multivariable regression models adjusting for treatment attitudes and demographics estimated the independent effect of ethnicity on treatment preference.

RESULTS

A total of 78,753 persons with significant depressive symptoms (CES-D>22), including 3596 African Americans, 2794 Asians/Pacific Islanders and 3203 Hispanics, participated. Compared to whites, African Americans, Asians/Pacific Islanders and Hispanics were more likely to prefer counseling to medications [odds ratio (OR)=2.6, 95% confidence interval (95% CI)=2.4-2.8; OR=2.5, 95% CI=2.2-2.7; and OR=1.8, 95% CI=1.7-2.0, respectively]. Ethnic minorities were less likely to believe that medications were effective and that depression was biologically based, but were more likely to believe that antidepressants were addictive and that counseling and prayer were effective in treating depression. Attitudes and beliefs somewhat attenuated the association between ethnicity and treatment preference in adjusted analyses.

CONCLUSION

Racial and ethnic minorities prefer counseling for depression treatment more than whites. Beliefs about the effects of antidepressants, prayer and counseling partially mediate preferences for depression treatment.

Racial disparities in diagnosis and treatment of depression: a literature review

The purpose of this study was to systematically review the literature to determine whether racial disparities exist in the diagnosis and treatment of depression in the United States. A literature search using PubMed of potentially relevant articles in English that include data from population-based studies examining the diagnosis and/or treatment of depression; or data from prospective studies stratifying the rates of diagnosis and/or treatment of depression by race/ethnicity and ethnic comparisons between Caucasians, African Americans and/or Hispanics. Initial searches identified 2,396 articles. On the basis of our criteria, 14 articles were eligible for inclusion in this review. Four included data on the diagnosis of depression in different ethnic groups; their results were not consistent. Twelve included data on treatment variability in the treatment of depression; overall these suggested lower rates of treatment for African Americans and Hispanics than for Caucasians. More research is needed focusing on ethnic variation in the diagnosis of depression. Racial disparities exist in the treatment of depression.

Disparities in depression care in managed care settings

The implementation of managed health care two decades ago produced sweeping changes in the delivery of health care. A large number of patients who have depression are cared for in managed care settings. Despite the fact that managed health care programs have offered the advantage of affordable and effective treatment of depression to many patients, racial and ethnic minorities remain underdiagnosed and undertreated. Diagnosis of depression, prescribing of antidepressant therapy, and referral for psychotherapy occur significantly less often in minority patients compared with whites. In the managed care setting, a number of issues at the physician level may negatively affect the quality of depression care, including attitudes toward psychiatry and mental health services, unfamiliarity with best practice guidelines for depression, and lack of cultural competency. On the other hand, a number of innovative approaches (eg, collaborative care) have demonstrated effectiveness in managed care settings. In some cases, physician education can be integrated with these approaches to assist health care providers in managed care organizations to provide the best possible depression care. This article focuses on issues relevant to depression care of minorities in the managed care sector, cites strategies for improving quality of depression care, and discusses implications for CME.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

Racial and ethnic differences in the mental health problems and use of mental health care

OBJECTIVES

We compared rates of mental health problems and use of mental health care across multiple racial and ethnic groups using secondary data from a large, nationally representative survey.

METHODS

We pooled cross-sectional data from the 2001-2003 National Surveys on Drug Use and Health. Our sample included 134,875 adults classified as white, African American, American Indian/Alaskan Native, Asian, Mexican, Central and South American, Puerto Rican, other Hispanic-Latino, or those with multiple race and ethnicities. For each group, we estimate the past year probability of: (1) having 1 or more mental health symptoms in the past year, (2) having serious mental illness in the past year, (3) using mental health care, (4) using mental health care conditional on having mental health problems, (5) reporting unmet need for mental health care, and (6) reporting unmet need for mental health care conditional on having mental health problems.

RESULTS

We found significantly higher rates of mental health problems and higher self-reported unmet need relative to whites among American Indian/Alaskan Natives and lower rates of mental health problems and use of mental health care among African American, Asian, Mexican, Central and South American, and other Hispanic-Latino groups. These differences generally were robust to the inclusion of clinical and socio demographic covariates.

CONCLUSIONS

Overall, our study shows wide variation in mental health morbidity and use of mental health care across racial and ethnic groups in the United States. These results can help to focus efforts aimed at understanding the underlying causes of the differences we observe.

Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer

PURPOSE

To assess the prevalence of depression among low-income, ethnic minority women with breast or gynecologic cancer, receipt of antidepressant medications or counseling services, and correlates of depression.

PATIENTS AND METHODS

Study patients were 472 women receiving cancer care in an urban public medical center. Women had a primary diagnosis of breast (stage 0 to III) or gynecologic cancer (International Federation of Gynecology and Obstetrics stage 0 to IIIB). A diagnostic depression screen and baseline questionnaire were administered before or during active treatment or during active follow-up. Self-report data were collected on receipt of depression treatment, use of supportive counseling, pain and receipt of pain medication, functional status and well-being, and perceived barriers to cancer care.

RESULTS

Twenty-four percent of women reported moderate to severe levels of depressive disorder (30% of breast cancer patients and 17% of gynecologic cancer patients). Only 12% of women meeting criteria for major depression reported currently receiving medications for depression, and only 5% of women reported seeing a counselor or participating in a cancer support group. Neither cancer stage nor treatment status was correlated with depression. Primary diagnosis of breast cancer, younger age, greater functional impairment, poorer social and family well-being, anxiety, comorbid arthritis, and fears about treatment side effects were correlated with depression.

CONCLUSION

Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.

Characteristics of depressed and nondepressed women with physical disabilities

OBJECTIVES

To describe the characteristics of depressed versus nondepressed women with disabilities.

DESIGN

Survey.

SETTING

Women were recruited through private and public health clinics and various community organizations.

PARTICIPANTS

A sample of 443 predominantly ethnic-minority women, ages 18 to 83 years, with physical disabilities.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Beck Depression Inventory-II (BDI-II).

RESULTS

Approximately half (51%) of the sample had scores in the mildly depressed range or higher on the BDI-II. Women classified as depressed were more likely to have multiple sclerosis, to be younger, or to have a shorter duration of disability. Only 44% of the women with scores exceeding the BDI-II cutoff for significant depressive symptomatology had received recent treatment for depression, with Hispanic women being the least likely to report receiving treatment. Depressed women reported significantly more health conditions, reflecting common symptoms of depression, conditions linked with depression in the general population, conditions known to be secondary to the primary condition, and conditions known to be common side effects of medications. Depression was not related to functional limitations.

CONCLUSIONS

Depression is a serious mental health problem facing many women with physical disabilities that does not appear to be adequately addressed by health care professionals.